jjniss’s AchillesBlog

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• 1. housemusic  |  February 9th, 2012 at 2:45 pm

  jjniss,
  I’ve pondered this question myself, and have tried out various combinations with hopes of finding a modality that would yield positive progress. For the record, my 5-month post surgery anniversay is Feb. 17th.
  Up to my injury I was an extremely fit and very athletic person. With a strong bodybuilding background, I know how to navigate the fine line between overtraining and undertraining.
  However, with this injury, the philosophy that served me well in the past does not apply. Basically, I found that working the tendon every day, or every other day, or every two/three days results in the same lack of progress. So there you have it, rest or no rest, both are equally ineffective. I do hope this is only my personal experience as others seem to be healing better than myself at the five month point. One thing I have not tried is the bourbon routine…maybe that’s what’s missing

• 2. ryanb  |  February 9th, 2012 at 10:31 pm

  I think the approach has to be modified to suit whatever phase of recovery we’re in. What works in week 2 is going to be different than what works in week 10 which is different than week 20.

  At the beginning, we’re mostly working to regain flexibility and range of motion. That’s something that I think you can work multiple times every day.

  Then we’re on to weight bearing - getting the ankle used to supporting our weight again. These PT type exercises are probably still something you can do almost every day- but a good PT session wiped me out for the day.

  Finally, we’re onto rebuilding our calf muscle strength- I talked about this is in a recent post; but I think once every few days is probably optimal.

  I guess another way to think about it is: the harder and more intense the therapy/exercise, the more rest time you’re going to need to recover. At the beginning, we’re really weak- and by design are not putting very much stress on the injury. So, the frequency can be much higher. As strength improves and we work it harder, we’re going to need more rest.

  Lastly, I’ll say that my approach was to establish a discomfort level I could tolerate, and tune my rehab such that I was always near it. For a very long time, my swelling and pain level were fairly constant- but as time moved on, I was able to do more and more; working the joint harder and harder. Alternatively, I could have tried to hold a more constant activity level; and hope for improvements in my pain and swelling. I chose the former; because I was striving to get back into my sport ASAP… AND because I think it’s the path to an overall faster recovery.

• 3. housemusic  |  February 10th, 2012 at 12:02 am

  ryanb,
  Are you able to complete five single heel raises on your operated tendon?
  How soon after surgery did you reach the major milestones such as walking without pain, walking without limping, and doing the one heel raise?
  I am curious as you seem to be on a fast track and I am on a very slow track…

• 4. ryanb  |  February 10th, 2012 at 12:34 am

  Fingertips against the wall for balance, I just popped off 20 consecutive (reasonably good extension) single heel raises. I could have kept going, but it was starting to hurt

  Most of the milestones are more qualitative- it’s hard to put a date on “walking without a limp”, but reviewing my data, I’d approximate my major schedule milestones as follows:
  2-shoes: 5.5 weeks
  Walking w/o pain: 6 weeks (IF I was slow and careful)
  Outdoor cycling: 7 weeks
  Skating/skiing: 10 weeks (big milestones for me)
  1st single heel raise: 12 weeks (pop!)
  Jogging: 15 weeks
  Single leg jumping / shuttle runs: ~18 weeks

• 5. shootingthebreeze  |  February 10th, 2012 at 5:27 pm

  Ryan is a machine, and has been a most excellent example for me to follow being about a week behind
  I can pretty much do everything I could do before my full rupture, just not with the power I used to. The strength is returning slowly but I am now at last able to really have a go at cardio based physio hitting the treadmill as well as the bike.
  I reckon over the whole period I’ve put on nearly a stone in weight, however that period also include Xmas as well as the whole reduced mobility issues.
  Coupling a 3 sessions per week cardio / physio regime with whatever fun I can have at a weekend, I should remedy the excess lard and build up Achilles strength relatively quickly.
  Having a desk based office job also means that I can rest between sessions so perhaps that has helped my own progress?
  Have to admit to feeling nervous starting to jog on the treadmill …. Maybe not helped because I was wearing the same trainers as that fateful evening when it all went pop !!!
  Work it, rest it ….. Get fit soon folks

• 6. normofthenorth  |  February 12th, 2012 at 3:11 pm

  Ya, ryanb covered this topic quite thoughtfully — and his post gave me a bunch of serious second-guessing thoughts during my recent ski week, which was characterized by thigh-draining effort EVERY day, resting only after the lifts closed. . .

• 7. jjniss  |  February 12th, 2012 at 6:09 pm

  Agree with ryanb’s point about the type and intensity of exercise that is effective in week 2 of rehab is not the same as what works months later in recovery. And I it reminds me to modify my calf strategy, need to up the intensity (more about that later).

  For me the biggest learning take-away is pushing oneself at every level of recovery to something just shy of discomfort. Ryanb has been a great role model for that. However it’s important to differentiate between physical discomfort and emotional discomfort.

  About physical discomfort thresholds, a core element of my rehab strategy has been never do any exercise or activity that had the remote possibility of re-injury. I’m 57 years old and don’t need to re-experience the first 3 months of healing and recovery ever again.

  Of course sh*t happens, a slip off the curb or getting in and out of the shower (a very scary place for those first few weeks!) and bam it’s hello velcro boot. But my strategy was never to be one of those people that got hurt during physical therapy or “going for it” as my tendon felt stronger.

  On the other hand it’s important to push oneself or recovery progress can be too slow. For me that has happened in fits and starts. My balance has recovered quickly, I can wobble board like a pro. But my calf strength still isn’t where it should be. I can do maybe 80% of a single heel raise (need some help with the good leg) but I’ll get there.

  So to goose that calf do need to push myself (more) physically but at 5 months the probability of re-injury is much lower than 5 weeks. Of course that depends on the type and intensity of additional exercise so will always need to stay within my core maxim of “do no harm” (but don’t be a wus).

  Exercise time is also an important element to rehab and recovery. For some people it’s a lot less (or more) than others and results will bear that out. On the other hand recovery milestones tend to plateau so there are periods where there is lots of hard work and not a lot to seemingly show for it. However at some point improvement bounds ahead which would not have occurred had the hard work during he plateau not been put in.

  The time I allocate to daily rehab is about 45 minutes, 25 minutes of specific exercise and another 20 minutes or so of accumulated exercise during the day such as furtive sets of single (nearly) heel raises. Part of the 45 minutes includes stretching hamstrings, quads, core and upper body.

  45 minutes is about what I’m capable of, physically and emotionally. It’s enough to show consistently inconsistent progress with enough assurance that I’ll reach my goal of being a fully functioning biped a year after my injury. Of course I’ll be putting in that 45 minutes a day for the rest of my life if I know what’s good for me.

• 8. kiwiclaire  |  February 13th, 2012 at 4:50 am

  I’m in your camp jjniss - don’t want to re-rupture it pushing myself too hard, yet not end up being a wuss. I have been commiting about the same amount of time as you each day and basically i’m just slowly increasing the activities that I usually did pre-injury as I know these well and can therefore graduate them easily - these are walking, swimming and horse riding.

  However, a non pre-injury exercise that has made the biggest difference is working the muscle as it elongates (heel over the edge of a step) i.e. eccentric contraction. On the advice of a sports physio they said forget the stretches and concentrate on this - however I was careful and had most of my weight on the good leg and holding on, and still have (13.5 weeks) but it made a huge difference in the range of movement and I always do some reps first thing in the morning.

  In the pool as well as my usual swimming I also do hopping, walking forwards and backwards - with water waist and above - water at chest height = 10% of bodyweight through feet. I can do a single heel raise with water at hip height so reckon that is around 60-70%

  I’m now increasing my walking on small road hills and am back using the geeky walking poles for this so I don’t limp.

  I’m just hoping that my progress is going to be slow and steady over the next few months and I’m being careful not make any plans which put pressure that I have to be at a certain level by a set date.

• 9. jjniss  |  February 13th, 2012 at 11:22 pm

  @kiwiclaire
  kiwiclaire, thank you for reminding me about eccentric contraction. I read about the importance of it in the weeks following surgery when I was not doing much of anything, forgot about it.

  I’m including the movement into my daily routine, did a set a little while ago. I’m sure I’ll be sore tomorrow!

  I do need to stretch a bit first thing in the morning and after I sit for a while. Not much, just enough to let my cranky tendon know I’m watching it.

  I try to do what I call an hour long therapeutic walk a few times a week, a gait with an exaggerated push off on the balls of my feet. If you know Monty Python think of a different version of “silly walk” It’s strenuous and the best that I can do in lieu of running.

  I should spend more time in the pool but I’ve never been crazy about swimming. And the pool at my local LA Fitness is too warm and has enough chlorine to kill most forms of organic life.

  So for those of us in the slow and steady camp of recovery, stay the course! It’s clear that we’ll never be finished with recovery, well me anyway. Just another reminder that I’m 57 not 27, no less committed to recovery just more patient, like it or not.

• 10. housemusic  |  February 14th, 2012 at 4:10 pm

  @ryanb,
  Thank you for posting your milestones. I wanted to bring your case to my PT.
  There are five ATR victims including myself undergoing treatment at my PT facility, 3 females, 2 males, all of us are five month post surgical repair, ages 33 to 55, all except one involved in athletic activty. And all of us are far behind you in recovery. Here is a brief recap:
  -two males were just discharged after 3 months of PT, both with minor limp, both are unable to run but they can jog lightly, neither could complete one single unassisted full heel raise.
  - one female discharged and advised to return once a month for evaluation, she has noticeable limp, some pain at push off, cannot run, can do treadmill.
  - two females still on PT, we cannot complete one single unassisted heel raise, we still limp, some discomfort at push off, we cannot run. Both of us had wound complications that were resolved at eight weeks post op.
  The PT said all five of us are following what is considered a normal healing pattern for surgical Achilles repair, which is supposed to be faster than non-surgical. The PT is not following a an ultra conservative method, and he is up to date with the latest protocols. Unless I am missing something along the way, you are quite exceptional in your progress!

• 11. jjniss  |  February 15th, 2012 at 4:37 pm

  @housemusic
  Hi housemusic — Seems to me you and your fellow ATR’s are following a pretty typical recovery pattern. Yeah the 2 guys seem to be a bit ahead of you but remember every case is different (more about that later).

  Recovery quality and rate can be thought of as a statistical bell curve. Most of us are in that 60% middle with a few outliers like ryanb in the 5% of exceptional recovery. Recognize ryanb is extraordinarily motivated executing a recovery strategy which is probably comparable to a professional athlete. Most of us do not have the gumption or lifestyle to do what he does, he’s remarkable in that respect.

  Both ryanb and normofthenorth are wellsprings of information and share it freely, which I’m very appreciative of. I’ve modeled much of my nutritional plan and rehab on what I’ve learned from them (surprisingly I still like jello :))

  You are probably at a recovery plateau which is part of the process but still frustrating. And about the reality that every case is different; Yeah I’m doing pretty well in many aspects of recovery but remember I still cannot run and remain unable to do an unassisted single heel raise.

  My ATR involved the tendon and entire calf muscle (gastrocnemius and soleus). The surgeon cautioned me my recovery would be longer than most and that with a zealous dedication to rehab.

  I may never be able to do a smooth unassisted single heel raise even after I’m fully recovered. The anatomy of my repaired calf muscles might be too compromised to work “normally” or at least as they were originally designed but I will run again. Just perhaps not as fluidly as I did pre injury but then again at 57 fluid running might be an oxymoron!

• 12. ryanb  |  February 16th, 2012 at 11:36 am

  Sorry for the long delay Housemusic… part of my recovery process is weaning myself off of the Achillesblog site Just got back from a little vacation, away from the computer. I will owe you guys a 6-month update soon.

  I’ll, of course, be interested to hear what your PT has to say; though I don’t really expect the feedback to be positive. Keep in mind that my recovery schedule was orchestrated by myself; and was not (at least initially) doctor approved. Once he saw the progress I was making, my surgeon came around and was quite supportive; but his initial plan was to cast me for 6 or 7 weeks.

  I found this site just a day or 2 after my injury, and did a lot of reading here. But, you might notice my first post wasn’t until I was a month in. Even here, among friends, I waited until I was pretty far along, and committed to my plan before soliciting additional feedback. I had enough folks telling me to slow down and to follow doctors orders.

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