Worst fears realised

Managed to get a private appointment with the consultant who performed my surgery. Unfortunately this confirmed my fears, basically my tendon is too long and I have too much dorsiflexion. MRI scan in a couple of days will likely confirm this. Spot of pain is likely to be the peroneal tendons trying to compensate for the weakness of the Achilles. MRI should show whether there is actually a re-rupture or tear. Although really bad news I’m glad I got the appointment as when I saw the registrar he told me to come back in 3 months and continue the physio. The consultant was off to “educate him” as I left today.

How could this happen? Well I probably have myself to blame by coming out of the boot too early and hence over stretching the tendon too early. How/when who knows! By the time I had the first private physio session I noted my foot was already back to neutral and at that time I was still wearing the boot with the wedges, but I had taken it off for sleeping and had been walking around without it on. Would this have been enough to over-stretch the tendon, probably, although at no time did I feel this was the case and I never had any pain. I came out of the boot because I felt I could and it felt good, but the consultant today suggested that it hadn’t been communicated to me correctly that the boot simply wasn’t optional. So, I guess a word of warning for those pushing it out there, without the boot it is possible to over stretch the tendon!

Where now for me? well only one real and practical option that is to have the tendon re-repaired if I want to get back to any sort of active pursuits. Left alone the tendon will remain too long and I won’t have any power in it, I’d probably be left with a slight limp too. MRI scan on Friday should confirm the route, the question for me will then be when do I want to start this miserable process all over again. The thought of a cast and NWB and then weeks in a boot is really depressing. I can’t do any more damage as I am, so I may well end up putting the enevitable off for some considerable time, like after the summer, but that puts skiing in Feb at real risk. 

Bugger!

11 Responses to “Worst fears realised”

  1. 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

  2. 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 that is not the case, I really wonder if you have a problem that requires surgery. If the tendon is too long to let the calf muscles pull your toes down as far as they should, then that is a problem. (Even then, is surgery the only way out?)

    How exactly did the doctor decide that you have a surgical problem? I imagine I’m sounding like some kind of expert here, but while I’m not an orthopod, I am a doctor and an old athlete, and I understand basic body mechanics. If I were in your shoes, I would be really, really sure another surgery would actually improve things before going through with it.

    Would it be so bad to keep working on your calf strength for a few months and see how much things improve? Even if another surgery is indeed necessary, I would think calf strengthening in the interval would be a good idea, anyway, unless it turns out you have a partial rerupture that precludes strength work.

    Doctors don’t always get things right, (and that includes me, of course). When my son was born, for example, there were concerns about infection, but the newborn specialist on call that night decided against giving him antibiotics. The pediatrics resident on call knew me, though, and asked if I wanted him on antibiotics. I did, and she ordered them and the accompanying tests right away. That was a very good thing, as his blood test grew a nasty germ that I have personally seen babies die from. Had the antibiotics not been started promptly, it might have been a disaster.

    I hope you don’t mind me being such a skeptic, but that is my nature, and also my training as a scientist. That’s partly why I pushed my own rehab in the first place, (although my dorsiflexion range of motion still falls slightly short of what my other foot can do). If my example led you down a dead end road, and now you really must retrace those difficult steps, I am very, very sorry. I strongly encourage you to be sure, however, that a repeat surgery truly is going to help.

    Best wishes,

    Doug

  3. 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 further surgery won’t be until some future date so I’ll maybe forced to try and build up some strength before going under the knife again.

    As it stands, I do think I over stretched the tendon (or maybe it was just repaired “long”) by doing something, although I was always careful. If this is purely a case of just coming out of the boot too early and allowing the foot to dorsiflex before it should then that is maybe a potential warning for people pushing the rehab.

    The real bugger is that if I do have to gor through it all again (and that’s what looks likely) everyone around me will tell me to follow doctors order to the letter, so I’m looking at the lengthy NWB, the weeks in the boot and all the things I really wanted to avoid for all the right reasons.

    I’ll post after the MRI.

  4. 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.

  5. 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.

  6. 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 unlikely, but intuition often turns out to be wrong. How about the calf muscles shortening? No doubt they can to some degree, but not as easily as the hamstring muscles. Just moving around in modern society, we stretch our calves near their limits much more than we bend way over and stretch our hamstrings near their limits. Also, the hamstring/tendon unit is much muscle and little tendon, while the calf/tendon unit is proportionately composed of much more tendon, so there is less muscle to shorten.

    A nerdy side note is that people with shorter calves and longer Achilles tendons tend to do better in many sports. It always struck me as counterintuitive that professional basketball players often have such small calf muscles. Shouldn’t bigger calves mean better jumping ability? Well, it turns out that the elastic Achilles tendon amplifies the strength of the calf. We can all jump higher on a trampoline because the springs around the trampoline save our downward energy and then use it to send us back upward better than a solid floor can. A long Achilles tendon is like an internal trampoline spring, saving energy to send us up higher. Kangaroos take this effect to the extreme with long, stretchy Achilles tendons, giving them their amazing ability to bound around like they do.

    Back to the question at hand. Can some combination of muscle and tendon shortening happen on its own over time? If so, how much time? I don’t know of any really good information on that, although this site:
    herkules.oulu.fi/isbn9789514284342/isbn9789514284342.pdf
    shows that tendons can shorten some between 6 and 60 weeks postop, (see pages 43 and 47 in particular). Another site,
    ukpmc.ac.uk/articlerender.cgi?artid=1257737
    also shows significant tendon shortening in two of the patients between 12 and 52 weeks (figure 7). Are you willing to risk being less than fully strong for a few months (or longer?) to see what happens? Would such a delay, if it fails, harm the surgical result in any way? I can imagine that two surgeries, with the accompanying atrophy, too close together could lead to less eventual strength that two surgeries a little farther apart, that allow some strength recovery in between. Could the shortening seen in the reports at those two web sites be improved by limiting dorsiflexion with some sort of splint, and/or by sleeping in some kind of soft plantarflexion splint? There are probably other ways of parsing this issue that are escaping me.

    Best wishes,

    Doug

  7. 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 pulls your toes upward toward your knee. He said that early stretching helps the tendon heal in a stronger fashion. I did this stretch several times a day, and I did it as hard as I could.”

    I wasn’t able to do this until 3 weeks after surgery, you started it 5 days post-op, I just can’t believe that using the tibialis anterior muscle would over-stretch the tendon at this point.

    Thanks all.
    JG

  8. 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

  9. 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

  10. 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

  11. 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 they are and I’m pretty comfortable with that even if I’m not restored quite to 100% it is close enough and simply not worth the hassle to go through it all again. I think the only thing that would cause me to have another op at this point would be a re-rupture as a result of physical activity, if that happens then so be it, I’d really be no worse off.

    Thanks again for taking the interest, I trust you are well.
    Cheers,
    JG

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