Squash’ed

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10 years on JG,
where are you?

I fully ruptured my right achillies and on week 9 or 11? i am not sure as the dotors in london gave me no direction….
i basically went in a cast for 2 weeks and then boot.

boot info found on in the internet is confusing essentially if i include the cast im week 11….
if not week 9….

anyways im now without the boot indoors…

the achillies itself is still visibliy swollen and achy.
however i can weight bear…
the main issue is blisters and rash! no one seems to mention that!

hope you are fully recovered some what 12 years later”

Hi Doug,

Been away from the site for obvious reasons, but appreciate you checking in. So 15 months on where am I?
For now I have decided not to contemplate another op, I have no real reason to do this in that I can do pretty much everything I could before, I’m in no pain and the thought of that recovery period over again fills me with dread. I can feel my right leg is “different” from the left, but I don’t walk with a profound limp. So I have zero motivation to contemplate a re-repair. I didn’t ski in February, but that was largely due to other reasons. I can swim and I’ve been running with no adverse side effects. I know I don’t have the running pace that I previously had, but I’m not training for the Olympics! I guess I’m about 1 minute per mile slower than I was before the rupture. I haven’t ventured back onto the Squash court and suspect that would “better” expose the inherent weakness of the repair in terms of my ability to push off from that leg. I have, however, signed up for a sprint triathlon (400m swim, 20K bike and 5K run) in June and have no qualms about doing this.

As things stand I’m likely to leave things as t

Hi JG,

I think of you now and then, and I hope things have worked out well for you, however you decided to handle it.

Best wishes,

Doug

Hi JG,

I hope you’re doing okay, and enjoying the summer some. I can’t say I blame you if you’re too frustrated for words.

Best wishes,

Doug

I guess we’ll never know for certain if it was the surgery itself or something after. I just hope things can get better without another surgery, but if surgery is what it takes, then that’s what it takes.

Another thought on things that might encourage “spontaneous” tendon shortening, besides some sort of splint to limit dorsiflexion and a nighttime plantarflexion device, is, maybe, using wedges under the heel. I have no idea if any of that would actually help, but it seems plausible and seems unlikely to hurt anything.

Good luck!

Doug

Hi Doug,

Thanks for the detailed comments. Exactly the questions I’m contemplating at the moment. Had MRI on Friday, results in the next week or so. If I’m not going to do any further damage then any 2nd op will be postponed for so some (possibly considerable!) time, so I guess I’ll be a good test case to see how much strength I can actually get back during this period. Until I get the results of the MRI though can’t make much progress on the options. I’m pretty resigned to needing further surgery at some point. Going back over the last 10 weeks (and as peterh pointed out), I was already able to dorsiflex past 90 degrees when I first went to see the physio and I was only just out of cast and into boot (with wedges!) at that point, which points to potentially a “long” initial repair. I’ll certainly keep the blog updated with results and decisions.

Doug, just looking back at your blog, I was reminded of:
“My doctor’s instructions at that visit were to remove the splint a few times a day and stretch the tendon, but only by using the tibialis anterior muscle. The tibialis anterior muscle is the one on the front of your shin that

Damn, I was hoping your plantar flexion was okay, and someone was overreacting to greater range of motion only. I tried to find some information on treatment options for long tendons, and didn’t find much. Someday, when we have all the answers, there will be good studies of how to best handle this problem, but for now, a big decision (surgery or no surgery) has to eventually be made with insufficient information. A surgeon will, usually, suggest surgery. Non-surgeon doctors often joke that, “When you’re a hammer, everything looks like a nail,” when thinking of surgeons and how they approach problems. Unfortunately, the surgical journals are full of articles that basically say, “We (or I) treated a few patients this way, and it seemed like it worked.” The more gold-standard randomized controlled trial, where one of two treatments is chosen at random and compared with the other later on, is rather rare in the surgical literature. The relevant trial that would be ideal for you would be to have surgery compared with ongoing physical therapy without surgery. Can tendons shorten on their own with time? Intuitively, that seems unl

peterh: Be careful with those tight hammies. That equals low back problems. I am on a really aggressive hamstring stretching protocol right now. It is actually helping my low back.

jgsquash: I hope it isn’t so. It can be really frustrating going back in but if that does happen, you will be thankful one day. I am at that “one day” and I am really thankful I had it dealt with. I had to have both of mine lengthened . (Believe it or not the length of the Achilles is a huge problem the other way as well too.) Lot’s of luck wished to you.

Hi Jg,
I’m sorry to hear the news. I am very curious to follow your progress and the MRI results. Reading through your blog, it seems more likely to me that the tendon was repaired long in the first place since you only starting going and doing more activity after the physio realized you had gotten to “neutral and beyond” so early. Also, you seem to have had a different type of surgery as to most. The MRI will hopefully let us know for sure.
I also question whether the “too long” condition is permanent. The tendon will never get shorter, but won’t the muscles shorten over time if they are not stretched? I don’t know about you guys, but my hamstrings for example get shorter every year that I don’t do regular stretching. I can’t touch my toes anymore, and used to be able to.

Hey Doug, thanks as always for the thoughtful and insightful reply. Let me start by saying that whilst I had read your experiences with interest, whatever path my recovery took was my decision and my decision alone so there’s no finger pointing or blame here. Also remember that I was acting on my own feelings (and I really am no doctor) and advise I had got independently so there is absolutely no reason for you to be sorry.

To your points. Your brake cable analogy is the right one and basically I think sums up the problem which is with the tendon too long I can’t contract it enough. So I actually have the opposite of what I need, i.e. I can’t plantarf lex my bad foot as far as the good one. If I dorsiflex the foot then I can bring the bad foot further towards me than the other one. I’m lead to believe that surgery is the only way out to basically repair the tendon and shorten it. We could leave it, but like the brake cable no amount of the fine tuning adjustment is going to compensate for the cable being too long and the brakes will never work properly.

The MRI scan should reveal more and unless I’m required to do so any furth

Bugger, indeed, but I’m still wondering exactly what is wrong, what is meant by “too much dorsiflexion.” Does that mean that, if you sit down, put your two heels on the ground, side by side, and pull up your toes, your repaired foot comes up more that your other foot? More importantly, does that mean that you can’t plantar flex your repaired foot as far as your other foot? The latter problem strikes me as the crux of the issue, as greater dorsiflexion range of motion, in and of itself, isn’t a problem, unless perhaps you go that far a lot and it bothers other structures, like perhaps your peroneal tendons, if they don’t want to stretch that far.

I’m a cyclist, so I’ll explain this like the Achilles is a bicycle’s brake cable. If the cable stretches too much, you can pull the brake lever as far as it will go and the brake pads won’t squeeze the rim as they should. The Achilles equivalent of that would be contracting the calf muscles all the way, (as short as they can get, and do this against some light resistance to be sure it’s not gravity pulling your injured foot down), and the toes won’t go down as far as they should. If

hI, thats a really heart renching story, but your message is clear. Take care and I hope your decision is a sucessfull one and that you make your skiing trip.
Regards
Kevlowry

Thanks for confirming my progress to FWB. I can definately stand on the bad leg alone.

Hope your appointment with the specialist goes well tomorrow.

I did the Thompson test on myself. I’m at 6 weeks. The injured foot moves about 1/2 the amount of the good foot. I think this may be mostly because the muscle is smaller giving less effect when squeezed (think about the extreme if your muscle was thin like a string - it wouldn’t shorten much when squeezed).

thanks for all the comments, a quick update.

1. Lying on my back with my leg straight up as per Doug I get virtually no response on the Thompson squeeze test
2. Sitting on the floor, the injured foot does appear marginally more flexible than the good foot, although I think I’ve always been more flexible on my right side
3. The spot of pain is still there but appears to be easing. Actually the pain is more acute when I roll the foot inwards (is that the opposite of eversion?). I think the theory about the peroneal tendons is a good one.

I have managed to get an appointment privately with the consultant that operated on me for tomorrow so I’ll discuss all three points with him and report back.

Hi JG,

Yeah, I wasn’t very clear there, was I? I was thinking the whole leg pointing up, so gravity would tend to pull the foot into dorsiflexion and stretch the tendon slightly. As far as the tendon being too long, I guess one way to test that would be have both legs pointing up, flex both calves, and see if the injured foot points upward as much as the other one does. If it can’t, and the tendon doesn’t feel as tight as it should while doing that, maybe it really is too long. I’m a cyclist, so I’m thinking a long tendon would be akin to a stretched brake or derailleur cable that needs tightening up. (Maybe our tendons should have one of those barrel adjusters put in during surgery?) If the peroneal tendons are the source of your pain, everting the foot should hurt.

Doug

Thanks for the comments guys. Quick response as I’m about to go out. Doug I think you could be right, the pain is on the outside of the ankle and the peroneal tendons could be the cause. When you say shin pointing straight up do you mean shin facing the ceiling? or the whole leg pointing up in the air so the shin is actually facing behind you as you are lying down. I’ll re-try the test a little later. Part of me thinks I’m ok but part of me thinks something isn’t quite right.

Hi JG,

If I’m not mistaken, the Tompson test should be done while lying down prone, not kneeling on a chair. The difference is that your knee is straight; the gastrocnemius muscle (the outermost calf muscle) is pulled tighter since its attached to your femur. With your knee bent, only the underlying soleus can really get short enough to pull on your heel, but it is difficult to squeeze the soleus as it is underneath the gastrocnemius.

Anyways, I hope there’s no real problem, as a too-long achilles is bad and you will have difficulty getting full strength from it. I know my surgeon was worried about this and told be not to put any significant load on it for the first 6 weeks.

Hi JG,

Regarding the Thompson test, try doing it again while lying on your back and your leg up in the air, so that your shin is pointing straight up. Then pull your toes toward your knee, then relax, then squeeze the calf. The squeeze is more likely to work if you start from a slightly dorsiflexed (but relaxed) position like that.

If I’m reading your picture correctly, the pain is off to the side of the Achilles a little bit. The peroneal tendons go through that area, and may be the source of the pain. Perhaps the peroneal tendons got caught in some scar tissue? Maybe you could test this by using your own leg muscles to twist that foot so the ball of the foot goes down, and the little toe comes up (eversion).

Just a thought,

Doug

Thanks all. I can’t work out whether I’m worrying unduely and am being impatient or if there’s really something not quite right. Just rang the private secretary to get in (privately) and see the consultant who operated on me (under the NHS) would take until July!

I’m going to have see someone as my concerns are:
- AT elongation and hence squeeze test failure
- my spot pain

Seeing the NHS physio next week to might pursue NHS referral from her back to the consultant which might be quicker!

MRI might be an option but I’d have to have that recommended by a consultant for it to be covered.

jg, I would get it checked out asap, doesn’t sound right to me. NHS failed me miserably so I had to go private.

Get a second opinion, if for no other reason than you are troubled by this problem. Too many doubts in your mind at the moment and they need to be cleared. Maybe there is some mild infection there that needs to be treated.

I went Private fortunately I was covered by PPP, saw Dr. Dalal in Manchester, a good man.

Annie

Hi jg,

If you are thinking about having a private consultation with an orthopod - I would recommend the following surgeons who are foot and ankle specialists - based in London. I think they have treated sports personalities in the past. I personally, have not been treated by them - but came across their profiles on google:

1. Mr. James Calder (Consultant at Hampshire Foot & Ankle Centre - I think he also operates (privately) at the Cromwell Hospital in London.

2. Mr. Mark Davies (Consultant at London Foot and Ankle Centre - he operates at the following hospitals in London - St. John and St. Elizabeth (40 Grove End Road, NW8) - London Bridge Hospital (tooley street, SE1).

jgsquash: I don’t know what it would cost you or how hard it would be, but if you can get to a different doc (maybe a specialist) and maybe get an MRI going, that is the only way you are going to know for sure what is going on in there. Your description of weakness and sharp pain when loaded is very similar to how I presented 11 years ago when I did a partial rupture right where my Achilles attaches to my heel bone. It may be nothing but a different phase of healing but I wish I had gone with my gut and gone to a specialist earlier after my full rupture surgery (3 years ago). I just knew there was something wrong but my doc at the time didn’t give me much attention. I waited for 2 years and my new doc (a foot and ankle specialist) knew what was going on right away. He also didn’t try and diagnose me without an MRI either. Good luck! I hope it’s nothing. Keep us posted.

Hi Jg,

I still get pain around the heal area when I walk for a long period (20 minutes or so) of time. Massage seems to sort this out. I am 10 weeks post-op today and find that my foot is still week (although getting better with each day). I have noticed that my walking speed seems to have increase with time. I also notice that after a period of inactivity the tendon does feel tight and requires loosening. I also find that the flexibility in my bad ATR leg seems to be better than my good. I can probably dorsiflex slightly more on my bad leg than my good. I have not done the thomson test since the day of my injury - but I do see movement in my foot when I have my leg on my lap and I massage my calf in a certain region.

Thinking out loud and in addition to the questions above. Is there such a thing as too much dorsiflexion? Have I maybe over-stretched the repair too early and therefore the resulting tendon is “too long” and hence the lack of power…

The document here:
http://achillesblog.com/files/2008/03/ewb-maffuli.pdf

says:
“front slab was fashioned so that the patients
were able to plantar flex the ankle fully, but they
could only dorsiflex it to neutral, thus preventing overstretching of the repair.”

Once I was in the boot at 2 weeks I did do some dorsiflexion but always carefully and never more than body told me I could do.

I can’t believe I have over-stretched this as I have nice tight lump of scar tissue on the repair itself, but maybe I have?

Hi Smish,

That’s interesting, as my surgeon is a knee specialist. I wonder if his experience with knee ligament rehab influenced his approach with ATRs.

Your experience with your different surgeries does reinforce my belief that many ATR victims are being unnecessarily tormented with weeks of immobilization.

But doctors, like the rest of us, are often creatures of habit, and change comes slowly. I hope that change is coming.

Doug53: I have had it both ways. My first surgery was done with an extended immobilization period. My second and third were done with (different doctor from the first) immediate motion and rehab. Trying to recover from the first surgery was torture compared to the others. I can only support your theory. My second and third surgeries, I was required to pull my leg out of the boot with in 24 hours post-op (never casted) and start rotating my ankle, bloody bandages and all. My recovery was MUCH quicker and MUCH less painful. My third surgery which was done on a different leg than my other two surgeries, the doctor had to take the lower 2 inches of my tendon sheath completely out. This made it mandatory that I kept my leg in motion because scar tissue could attach and ruin all my mobility. On all 3 surgeries my Achilles was either blown apart or cut apart (to make longer) so I was still dealing with healing the tendon (among other things). Because of the job I use to have, I was able to talk with a well known sports orthopedist who works on a lot of professional athletes. He happens to also be in the ATR club. He told me that he feels t

This issue of the strength of the tendon versus the strength of the calf was much on my mind early in my rehab. Wouldn’t it be nice if our tendons had little meters that told us how much force they could handle without damage, so we could exercise to near that point but not go past it? Of course, they don’t, so we are left with guessing. The uncertainty is unnerving, because rerupture is a steep price to pay for overestimating.

Going by what I’ve seen in this blog community, the common approach is to do nothing for weeks, while the tendon gets stronger. This strikes me as excessively cautious. The tendon has some strength, maybe not much but some, soon after surgery, so why not take advantage of that and do at least some calf strengthening to lessen the eventual atrophy? My surgeon is somewhat aggressive, and said I could stretch my tendon, using my own leg muscles (tibialis anterior) only, starting at five days postop. I used that as my safe limit, and slowly worked up to calf strengthening with that amount of force, (pushing against my other leg’s tibialis anterior, by pushing against the top of my other foot), as I detail

Interesting. I’m at 5 weeks right now, and can push with 60lbs before I feel slight pain in my tendon. I could definitely push harder if I wanted. I guess my calf will keep getting weaker and my tendon will keep getting stronger until my calf is the limiting factor. I’m not supposed to be doing any rehab at all (according to my surgeon). How early did everyone else start calf strengthening?

peterh,

I can only speak for myself, but my answer to your question was different at different times. Up to eight weeks postop, (when I could first hold my weight up on my bad calf), I tended to chicken out before giving my all. My tendon didn’t hurt, I just didn’t feel confident yet going all the way on effort. (As hard as I’ve pushed my rehab, I’m nervous about rerupture, too.) Since then, though, I’ve pushed as hard as I can and as long as I can.

Maybe what you are getting at is a fundamental question, is your calf ever strong enough to pull the tendon in half all by itself? I don’t know the answer to that.

Doug

PeterH, in answer to your question about weakness, my answer would be YES. Yes to both parts. Remember your muscle(s) are weak or unable to do the work being asked of them no matter the effort. There is also pain weakness due to tendon stiffness, soreness, fear of reinjury. Pain helps us guage if we are going to hard or too soon. So my answer would be yes. I can always tell when I’m pushing myself and try to vary my routine of excercise as well to not overwork or underwork any one area. Hope this helps.

JIM

Hi Guys,

Just a question for you re-habbing folks. When you say that you are “weak”, what is the limiting factor? Are you pushing as hard as you can with your weak muscle, or is it pain in the tendon which limits your strength?

Hi jg,

At around 8 weeks, my ATR leg felt weak. When asked by physio to stand on one leg on my bad foot - i could only manage a few seconds at a time. I can now (9 weeks post-op and with practice) manage upto 45 seconds. At 8 weeks post-op I could not do (was not asked to by physio) any heal raises. Now (9 weeks post-op) I can do 2 foot-heal raises (although - I probably favour more weight on my good leg when I do 2-foot heal raises). A tip when doing 2-footed heal (calf) raises is to make sure that your belly-button is central and does not sway towards your good leg-side when doing the raises. I was also told to take approx. 3 seconds on way up and 3 seconds on way down whilst doing the calf raises and to use support if necessary. At the moment, I find it difficult to do 10 x what I describe as good 2-footed heel (calf) raises - but I do find that things get easier with time & practice.

At this stage I can not do one-foot heal raise on bad leg - it’s too weak.

Gotta go to work, so I’ll be brief. If you’re pushing down with 55 pounds, you’re fine. You don’t have a “lack of strength,” you’ve proven that you have 55 pounds of strength, and you will soon have more.

Doug

Thanks for the comments Doug. I don’t think I’m “cheating” as you describe, if I lift the heel on the bad leg whilst sitting I can feel it in the calf and heel. So that sounds promising! I have scales at home and have tried the “how much pressure with my bad leg test” at this stage I can manage about 55lbs pushing down with my toes and I’ve noticed this has improved over the last week or so. I’ll try the sitting calf raise with the scales in place and report back.

What’s worrying to me following the physio comments is the complete lack of strength in the bad leg and so the questions and doubts start to creep in so it is interesting to hear your comparable experiences.

Thanks again,
JG

Hi JG,

I’m not sure what the NHS physio means exactly by “complete.” If you can push your leg up with your calf while sitting, your tendon must be connecting your calf to your heel bone as it should. That’s exactly where I was at five weeks, nice and flexible but still quite weak.

The only bad alternative I can even imagine is if you are “cheating” and actually pulling your leg up with your hip flexor muscles, the muscles you would use to pull your foot right off the ground while sitting. If that is the case, you won’t feel added pressure on the bottom of your foot as the leg goes up.

Do you have a bathroom scale? If you still have doubts, you could put that scale under your toes to verify that you are indeed putting some weight onto your toes with your sitting calf raises.

I don’t know how reassuring I can be over the internet, but I really think you’re fine, and you just fell outside the “normal experience” of the physios you are seeing. As I said, what you’re describing is exactly how it was for me at five weeks.

Hang in there,

Doug

Hi rudedog,

I’m not finding I have to limit my time/distance walking. By the end of the day my leg is slightly swollen (gravity playing it’s part), and I’d say I’m tired but I’m not finding I *have* to rest it. Don’t get me wrong I’m not walking for miles or standing up endlessly, but I can basically live “normally”. The physio started me off stretching the tendon by keeping the bad leg out behind and ensuring it doesn’t bend and having the good leg out in front and bending this leg to give the “stretch”. To increase the stretch put the bad leg further out behind you. At all times though only use your own muscles to perform the stretch, i.e. no “dynamic” stretching or bouncing, basically keep it gradual and controlled and try and hold the stretch each time. I’m now working towards heal raises, this is my next milestone, i.e. to be able to do one!

It remains a long road, but I feel the uphill section is getting behind me.

Stay well.

Cheers,
JG

Hi jgsquash,

Good to hear things are progressing well with you. I was wondering how far or for how long you can walk in two-shoes unaided without discomfort. I have been in 2-shoes for about a week and can walk for around 5-10 minutes (albeit slowly) before I feel discomfort/tiredness in foot.

I have now been to physio 3 times in the last 7 days and have been doing a range of stretching exercises. I can’t do heal raises but the physio has asked me to (pretend) lean forward so that I feel it in the tendon. My flexibility is increasing, but still need a lot of work on strength. I will also start some hydrotherapy sessions shortly.

Hi

Thanks for posting on my blog. Good to hear you are back exercising and swimming. I’ve been doing lots of good foot cycling on an exercise bike, keeping the busted one elevated and out of the way. It is good to do some exercise and is helping to keep the lbs off!

All the best with your recovery, hope you continue to progress well.

Si