Posted by: johnsfbay | March 28, 2012

Frustrated with doc at 9 weeks

Hi all,

Just finished my 9 week post-surgery appointment, and the doc wants me to stay in my boot another 4 weeks, and won’t begin physical therapy until week 13…arrrgggghh.

To recap, I’ve been in the boot now for 4 weeks already, the first week I was PWB, and my foot felt strong enough that I went to FWB in the boot at week 6 (and essentially walking barefooted when in the house).  Putting the crutches away for good felt awesome…even better than getting the cast off.  My doc had me do ROM work with bands over the last 4 weeks, and grudgingly let me use a stationary bike with boot when I pressed him on email.

I’ve kept up my 2/week personal training sessions at the gym since my ATR surgery, which has really helped keep my core and upper body strength intact throughout the cast/boot period.  I would definitely recommend following a core/upper body exercise program during that timeframe - both for your physical and mental health!

Given that I have had only 3 doc appointments now in 9 weeks since surgery, at an average of 5 minutes time each, I wonder how much my doctor tailors his patient’s rehab plan based on actual progress, or just follows a set conservative schedule regardless of how well the patient is doing?

And lest I seem too hard on my doc, I am thankful that the surgery went well, the incision has healed nicely, and I am walking around very well in my boot.

I have a 3-week family trip planned to visit Spain in mid-April, so it’s probably prudent to keep following the doc’s conservative rehab plan so that I don’t risk a re-rupture, and jeopardize going to the Alcazar and Alhambra.  Wish I could have thrown the football on the beach in bare feet with my grandson, but that will come soon enough.

Slow and steady it is then :)

Responses

John, I share your frustration — and your opinion that the vast majority of protocol/schedule variations are due to personal preferences (many of them based on misunderstandings), and not due to customized regimens tailored for each specific leg. Old-fashioned conservative humans who become surgeons become old-fashioned conservative surgeons, and imagine that longer immobilization produces superior results, even when the weight of evidence says otherwise.
(Also, as you’ve seen, OS’s don’t actually DO much after the operation is over!)
If GerryR were hanging around, he might flame you about it being YOUR leg and not your doctor’s! And many others here have also either ignored their Doc’s advice or defied them, or gone faster with their tacit approval in some cases. (I remember “Gunner” fondly, offhand.) MOST of them have done fine, but maybe the “cowboys” who got into trouble didn’t share the details here, who knows?
If you haven’t printed out and read the UWO study’s protocol — e.g., at bit.ly/UWOProtocol — you should. And I think you should fax a copy of the study’s abstract to your Doc, and ask him if HIS results are anything near that good. (The whole study’s on this site.) And if not, or if he hasn’t documented his results half as carefully, then why would you undergo the inconvenience of a slower rehab based on an undocumented gut feeling?
Of course, that confrontational approach isn’t for everybody, when dealing with a God-like Surgeon!
One of the personal-professional challenges of going surgical, is that you are effectively tied to the one Doc, because most others won’t take you on. Not so much if you’re in a boot, non-op, where even a good PT can usually be a fine guide.

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John, I don’t know why that post is “awaiting moderation”, but could you please approve it (as the moderator) so it can be read by everybody?
Thanks.

Hi Norm,

Yes I printed out the UWO protocol at week 1, and have been using it as a guide to see how different my rehab protocol has been. Up until this last doctor visit, we hadn’t been that far off, so I hadn’t considered being too confrontational. I think I would have pushed back more for PT now, if I wasn’t going to be out of the country for 3 weeks.

I personally agree that some level of going faster than a conservative doctors rehab protocol seems prudent. As you noted, when I push my doc to do more, he generally says it is ok or at least doesn’t say no - like using the stationary bike with boot during weeks 5-8, or walking in bare feet around the house. Pushing the rehab is definitely a personal decision, and we each have to monitor whether those “unauthorized” activities cause any abnormal pain afterwards. It sure helped reading all of the rehab protocols provided in this blog, as it allowed me to add some “extra” exercises that I wouldn’t have otherwise based on my doc’s conservative approach.

I think that I’ll follow your path of non-surgical if, god forbid, anything happens to my other tendon, and also look for a good PT early on!

Thanks for your comments!

John

As one of those “problem patients” Norm describes, I just want to echo my agreement with his comments above.

This is your leg. Ultimately, YOU are the one who has to live with the short and long term consequences, and YOU are the one who makes the ultimate decision here. Strictly following all of your doctors recommendations is one possible choice. Aggregating all the info you can find about modern rehab protocols and implementing such a plan another possible choice. A few lucky folks (with progressive doctors) find those two choices align nicely. Others, not so much; and that’s when things get a little more complex and difficult. But either way- you are going to have to live with the outcome of the choice(s) you make here.

Well said Ryan!

If only I had the progressive doctor, as my entire family is telling me…listen to your doctor….don’t do anything stupid and get hurt before our trip…so it is a lot harder for me to say…well my doctor said it was ok for me to take a more aggressive rehab approach.

As it is, I’ve already done a fair amount of following the spirit, but not the letter, of my docs recommendations for rehab…I just don’t always tell the family right away ;-)

And much of that decision is based on the comments and information found on this blog, so again thanks for sharing your more aggressive rehab protocols!

What I would say is helpful for those just starting out is to get the protocol that your doctor will be following spelled out up front. I had fully expected my doctor to get me into PT and start in 2 shoes at the 9 week mark, and was surprised when he didn’t do that. I think I has assumed from looking at the protocols you all share that being FWB in the boot at 6 weeks would lead to that outcome. Now I realize that this was not in my doctor’s plan, and I should have known that ahead of time so that I could have questioned him more about it at the time.

Lesson learned!

I am 7 weeks post op & 1 week today I have been in the boot. I am PWB & still have a wedge in the heel & doing Thereband to get my ROM back to flat foot as I was in a cast for 6 weeks with toe pointed down. When I try & test my foot to see if I can go FWB I feel some pins n needles type feeling on the bottom of my foot. Can anyone give me advice from going from PWB to FWB? I want to try & take a few steps later today but just dont know when is best to feel it out. Also sorry about the writing, I was more detailed & lost it all when I tried to post it the first time, so thiw was a 2nd write. Thank you all… Good luck with recovery John.

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One more question… If my foot is not at neutral position yet, can I still try & walk FWB with the wedge still in?

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Thanks Mitch, sounds like you are doing well in your rehab.

If your doctor was like mine he said to start PWB and then move to FWB in a couple of weeks, with very little other instructions.

I followed the advice of the many bloggers and moved to FWB as soon as it felt right. The pins and needles, and pain in the heel is pretty normal and gets better as you walk more. I tried to walk as slow as necessary and added a wedge to my good foot’s shoe to keep a good gait (reduce limp to minimum) and reduce stress on the knees and hips. Because going FWB means getting rid of the crutches, I admit I pushed to get to that state as quickly as I could (ie 1 week vs docs 2 weeks). Also crutches put a lot of stress and strain on wrists, arms, shoulders, hips etc which is not helpful to recovery.

Good luck to you as well!

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Hi Mitch You will wake up all those nerves little bones etc and feel lots of sensations as you begin FWB. I am 3 months behind with problem with incision not closed but I am mostly pleased with my progress to FWB in open back shoes. I went from PWB 2 Days to FWB on day 3 in Vaco Cast for a week or 10 days then ditched the boot. I did use boot a few times walking my dog in the field as it is sandy and uneven ground. You will know your strength and ment grit will get you there. Nust be safe and smart so no reinjury or other injury occurs. O

Thank you for the replies!!
I just took my first few steps tonight & it felt good. Let’s see what tomorrow brings. The needles sensation went away after putting fwb on it for a litle while so I am feeling good about this finally.

John, my dr told me the same thing 2-3 weeks I would be walkin & nothing else, just I won’t start PT for 4 weeks if I even need it. I think most people do get pt though.

Doryt, 3 days to fwb…wow that is great. I hope your incision heels well. Most of the tape strips have fallen off my incision, but I started to help one of the last 3 & it was a little gooey still, so I won’t force it. Did you swelling last long?

Hey Mitch. I got my ATR 5 weeks ago, went the non-surgical route, was in casts for 4 weeks and just got my boot last week. Doc said I could go FWB as soon as I felt comfortable. Unfortunately, I didn’t get much of a demonstration as to how to do that.

For about 4 days I went PWB using my crutches then 3 days ago I started transitioning to FWB. Got rid of the crutches today. For me it seems like the key was leading with my booted foot and letting my good foot catch up. Walking briskly seems to work better than walking slowly. It seems illogical at first but it really does work, at least for me. The biggest challenge is developing a gate that isn’t too awkward. I slightly bend my booted knee, lean forward a bit and kinda swing my arms a bit to maintain momentum.

You might also try searching YouTube for “how to walk in a cam boot.” There are a few videos that I found that might help you.

I’ve got 1′ wedges and outside of making it more difficult to balance, they are okay to walk in.

First off Congrats on ditching the crutches, Wow Starshep no surgery? Was it a full or partial tear? My injury playing raquetball was a clean 100% tear & my dr said I needed surgery after just touching me for 5 seconds & said 50/50 without it or 95-100% recovery with it. We booked surgery for 2 days later… I requested an mri as I wanted to be sure of my decision, but he was correct. I sure hope you heal 100%, sounds like your well on your way. Thanks for the you tube & other advice…….

Mitch, you probably don’t even want to know what the latest studies on that topic are showing, but they’re around, and even on this website. Your surgeon may have been correct in diagnosing a complete tear, but all the modern studies comparing surgical to non-op protocols have limited themselves to complete tears (and gotten excellent results with non-op), so he’s also wrong.

Many of us found that some extra sensitivity in the bottom of the recovering foot lasted a LONG time. I switched from exercise sandals around the house to Crocs, for the extra gel padding. And I added some gel padding (insoles) to my boot, then to my shoes, too.

starshep, your “lead with the boot” approach is the way to go when starting FWB. Also, (1) make sure your boot stays pointed straight ahead, not angled out, and (2) build up your other foot/shoe/leg so that your hips are straight. Walking with one long leg and one short is awkward and even dangerous for your body, so avoid it. Bending your booted-leg knee is NOT a great work-around. Bloggers here have found and used many techniques to get that other foot as high as your injured one. The specific technique doesn’t matter much, but doing it does matter.

Mitch, It was a full tear. Partial tears are pretty rare. A simple Thompson test confirmed it. You could also feel how slack the ruptured tendon was compared to the other. I guess I have the benefit of a young orthopedic surgeon and the ability to spend the night before I visited him doing some research on the Internet to see the advantages (in my case, being 59 years old and not really engaged heavily in sports anymore) to the non-surgical option. My primary care physician, who I saw the day of the rupture, didn’t even know non-surgical was an option. Since I opted for non-surgical, no MRI was needed. Big thanks to normofthenorth for helping me keep my mind at ease about the decision.

normofthenorth, thanks for pointing out about building up the other leg. After 3 days, I certainly have not mastered the technique and appreciate the advise.

It sounds like your doctor is being uber conservative (in my opinion). I can only compare to my own experience and I was on a stationary bike the very first day of PT…..I think you are totally in the right for requesting something a little more rigorous, especially since you have been keeping with your personal training. It just seems to me that you could definitely be further along. Trust your own body.

Hello all - Wanted to comment on a few things, specifically on incisions and going PWB and FWB too early. If your incision isn’t totally healed properly and you attempt weight, the incision could reopen and expose your tendon. I don’t want to sound like a braggart, but my surgeon is one of the top ortho surgeons in the U.S. He said the reason for a cast is to protect your incision. The longer you have the cast on, then the longer it needs to heal in the doctors opinion.

I know we can trust our own bodies, but when the incision is still “oozing” or is still mending with staples/stitches like mentioned above, I’m under the impression going to weight is a bad idea.

When going to PWB and FWB, it’s not that the repaired tendon can’t handle it (it’s stitched together pretty nicely after surgery), it’s that being off your leg and foot for a few weeks or months renders that part of your body much weaker than normal. Walking normally on it and moving as if nothing happened may result in a movement or action that your weakened muscles can’t handle, and you risk further injury.

I just want you to be cautious upon your return. It might seem like you can handle it, but this tendon and these muscles surrounding it basically have to be built up from nothing again. The body can most likely warn you of a pending problem or of too much stress via soreness and some pain, but it can’t warn you about a weak muscle that is suddenly activated and can’t handle the activity (walking, bearing too much weight) you attempt to undertake too early.

Sorry for the rant. Just want you to be safe.

Hi Matt,
Not sure if this is the appropriate place to ask this question but here it goes. I am 14 months post surgery and am about to venture out to playing basketball again. I’ve been running on treadmill and doing tons of other cardio without any issues. Some soreness, but nothing over the top. I used to wear ankle braces (ASO figure eight brace) to help support my bad ankles that have been sprained often. Do you know if this kind of brace would NOT be recommended after having achilles surgery?? I’m just not sure so any guidance you or anyone else here can give would be much appreciated!

Thanks,
Steve

Walkel,
I agree, very conservative rehab - only banded ROM to this point. My personal trainer at the gym has assessed me over the last six weeks and thinks my body can handle more aggressive exercises. I’m going to look at the physical therapy regimens again on this blog’s home page for 8-12 weeks and do some of those on my own, as well as start going back to my aqua aerobics classes with some modifications on some of the moves that are achilles intensive. I like your PT regimen from your recent post - squats, stairs, etc and can’t wait to finally get to see a physical therapist so that I can start doing those types of activities. I would also like to be playing soccer again by the beginning of 2013!

John, make sure you’re GRADUAL about moving from a slow schedule to a faster one.

Matt, you may be overestimating the strength of ATR-repair sutures, or underestimating the tension that the body’s biggest strongest tendon normally experiences. Even post-op, most of the strength in a recovered AT isn’t from the sutures, it’s from our body, laying down a sequence of increasingly “good-tendon-like” materials where the tear was. That sequence can’t proceed without some tension.
What you say about fragile incisions makes sense, yet the studies that hustled all their patients through rehab (incl WB) consistently show rerupture rates and other outcomes as good as, or better than, those that waited longer.
I’d love to believe that OSs tailor each patient’s specific schedule (& maybe you hit the one who does), but I don’t. There are too many patients right here who are on archaic protocols with no justification within miles…

Steve, ask your surgeon’s office. I can’t think of why it would be contra-indicated, FWIW.

Norm: yeah it seems like from reading a lot more the docs can be too conservative a lot of the time. I’m not too too familiar with the protocols. Can you direct me to them? I’m curious to read about them, a lot of users here reference them and I’m curious.

Matt, my fave is the UWO one. The study’s linked from here, and I think the published protocol is linked from the end. Or you can find my version of it at bit.ly/UWOProtocol . (That’s the version the authors faxed to my surgeon ~18 months pre-pub.)

Matt: not sure from your response if you have already seen the achilles blog’s home page, where they have a link to many rehab protocols:

http://achillesblog.com/atr-rehab-protocols/

I think I have read and printed out nearly all of them to improve my conservative rehab routine - very useful information!

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Hello,

I had my surgery on Jan. 27th, 2012. At the 2 weeks appointment, my surgeon placed me in a hard with my ankle close to 90 degree bent and told me to go FWB. He said to use pain as my gauge to how much FWB I should attempt. At 5 weeks I was placed in a boot walker and instructed to keep it on at all times with FWB. I felt good, so only wore it when outside and at work. I was totally out of the boot at home. I also began physical therapy at 5 weeks post op. Physical therapy is going very well and I see improvements weekly…both flexibility and strength. My left achilles is still a little tight and most noticeable when descending stairs. I have been completely boot free for 2 weeks now against my surgeon’s advised. I believe prolong immobility will delay your healing. Prolong immobility also promotes muscle atrophy, especially in the calf muscle. I also noticed more tightness and lost of flexibility when I was in the boot walker. Use pain as your gauge and good luck. Your surgeon is giving you advised based on statistics and the “norm”…you must consider, that we are all different and heal differently.

My doc initially wanted me in a cast for 8-10 weeks after a 2-week post-op splint. After readling all the great info on this blog and other sites, I asked her for a more aggressive approach. At my 2nd visit, she had done some research herself and agreed to take my cast off at my next visit and put me in a walking boot. No PT until 10 weeks post-op, though — and no dorsiflexion of the foot until then because she said this could cause too much elongation of the tendon. I’m glad she’s willing to work with me.

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