Posted by: johnskier | June 16, 2008

Doc’s visit, PT, various…

FOUR-MONTHS PICTURES:

Four months also

Four months picture.  </p>
<p>Notice swelling and tendon thickness

LAST DOC’S VISIT: (June 5)

Range of motion: Great. It measured out at 100% of the right leg, but when I bend down my right knee definitely goes further down so I don’t think it’s quite 100%.

Cycling: I suggested that on my bike I loosen the clipless pedal so that I don’t have to put much pressure to twist out. He agreed. He definitely said biking is a great thing to do.

Scar: Put on vitamin E; poke a hole with a tack in the gel caps and spread it on.

Golf: Ok

Skiing next year: May have to get my boots worked on so that the “lump” where the repair is won’t be bothered. I asked about stretching more before skiing, and he said the main thing is to build my strength up.

Told him: “I hope not to see you again, other than downtown for a beer.

I’m clear to do whatever I can do.

They get all these professional athletes at this clinic, and there are all these pictures and jerseys on the wall with autographs from the athletes with something like “Dr. XXXX, thanks so much for saving my career”.

So I wanted to show my appreciation, so I sent the Doc and his staff flowers with a note that said something like “I don’t have a jersey to sign for you, but wanted to express my appreciation…” I thought it was pretty funny. I hope they got it since I am strictly a “recreational” athlete.

I asked if this is likely to cause other problems (knees, hips) , is this is a “structural” change? He said no, that ROM is great and the scar looks great and just get the strength back.

PHYSICAL THERAPY:

I got the “it’s all up to you now” speech. Think I needed it.

I ran out of insurance money for PT. Mine was paid 100% but limited to $2,000. Seems to me a co-pay each time with a higher limit makes more sense, as it costs me something each time and at least I have a choice to continue longer without too much “damage”. I offered that suggestion to the company.

So I’m cutting down to every two weeks for now.

I aked if I could pay for a certain number of sessions private pay at a discount. They said no, they don’t do that.

ROM - great

Continue with ice as needed. I will continue to get swelling.

Strength is the main thing right now. Main things: Theraband exercises, heel raises, standing on one leg, standing on one leg and bending to a “T” (flat back, head up, arms out). Also, my wife is a certified Pilates instructor, so we have a “reformer” at home. I can do a bunch of cool exercises on that to build strength (including “prancing”, heel raises on the machine, etc.)

OTHER:

Dirt biking: Went to Moab dirt biking with one of my daughters and a friend and his daughter. So the day before I was loading my bike on the trailer and created a pretty nasty problem in my back & hip on the right side (left achilles injury). I think mostly it was from being stupid and not having a ramp. But it may have also been partially from weakness from the achilles injury. Anyway, I went to a chiropractor who does Active Release Tecniques (ART). Well, that helped a ton and at least I could ride the bike and dirt bike that weekend.

I was very careful on the dirt bike as I didn’t want to instinctively put my foot down for balance and cause a problem. The dirt bike was fine on my back/hip, but the mountain bike, especially, was not pleasant.

I’ve been back for ART a few more times and he also recommended massage. Well, this guy that he works with does an amazing massage if you like pain. Talk about getting the right spots. When combined, I think the massage and ART have been helpful in getting me back to normal. Man that massage hurts though.

Golf: Walked 9 holes Saturday and that really seems to be a good thing.

Think that’s it for now.

Posted by: johnskier | April 27, 2008

Docs, Physical Therapy…

Docs:

Docs could do a better job of educating patients….thus the need for this site. There are so many questions and we don’t even know enough to ask the right questions. This site has really helped with that. Doc Ross had a good idea to make appointments for early in the day. Also, I really think it’s important to come up with your list before you go in. I will have a couple of suggestions for my doc (which I will tell him). One, have an information sheet, which includes “frequently asked questions” that they hand out at the first visit. It could include a lot of stuff that’s on this site…diagnosis, treatment options (surgical, not surgical), surgery, benefits of e-stim, massage, etc, recovery protocols and ranges, physical therapy, etc. Maybe docs are nervous about this because if they vary from the information, and a patient has a bad outcome, it increases their legal exposure. Not sure. On the other hand, I think it could be general enough to provide information. I saw something like this in my doc’s office relating to anterior cruciate ligament injuries. That injury is common here in Vail. This pamphlet appeared to be prepared by a third party and “rubber stamped” with the doc’s name. (there’s a business for you Dennis!)

Two, provide written instructions for patients to take home. For example, my doc (who always listens, answers my questions, and takes the time I need) doesn’t usually write anything down for me other than a scrip. One time I got instructions on a business card. But it seems to me it would be better for patients to write down specific instructions on a form of some sort, and it frankly would be better for the docs too. No doubt they have notes in the file as to progess, instructions, etc., but I think a copy of written instructions in the file would be good. If I have a problem and it was the result of doing something I was told not to do…that would be clear.

Other observations - first PT:

First week is: stretching with towel (toward me), more circles, alphabet, up, back; full circles, go slowly, work on regaining more range all directions. Also, I have an exercise to improve the strength in my hip. It’s weaker from being less active. You might ask about that. Ice after doing my exercises, as necessary.

My calf is really weak. Even if I wanted to, I couldn’t raise up on my toes on my repaired leg (and let me tell you, I DON’T want to). I am limping because I can’t extend my toe (I go heel to toe, but can’t put much pressure on the toe/front of my foot). I’m “trying” to though.

I also rode the exercise bike yesterday and i just can’t put any pressure on the pedal. Weird.

One last thought…I was told I didn’t need a wedge in my shoe, but because of the weakness and trying to extend my leg when I walk, I actually put one in for now. Feels more comfortable.

Patience Grasshopper (remember that TV show, David Carradine?) (that’s what I tell my kids when they are being impatient. :)

Posted by: johnskier | April 24, 2008

Ditch the *$%#@ Aircast!!

Time flies when you’re having fun!!

So let’s see…I’ve been in the Aircast for 5 weeks…2 weeks 50% WB, and almost 3 weeks FWB. I’m now almost 10 weeks and ditching the Aircast as of today. Slower than many patients but I’m comfortable with the more conservative pace of recovery. Have been doing ROM work for 5 weeks.

So…today…into a shoe. That means I need to take two shoes of each kind on my next trip! No wedges. He said I didn’t need the wedges but if it was uncomfortable I could put one in for awhile. ROM is good, the incision has healed well. (a play on words…achilles “heal” or “heel”?) :)

ROM is good. Start physical therapy tomorrow and it’s limited to ROM, more passive resistance for two weeks. After two weeks, start on strength work.

As for activities: I can walk “all I want”. I can keep exercising on the exercise bike but without much resistance (been doing it with the boot). He wants me to wait to get on my road bike for 4 weeks (after 2 weeks of strength work at PT). I can “chip and putt” on the golf course in my shoes. If I want to put my boot on, I could play/practice full swing. Basically my take is that he wants me to have 4 weeks of PT, including 2 weeks of strength work before I do anything that is too strenuous. I asked when I could “jump off a cliff”. He seemed to contemplate that…and what I meant (jumping off a cliff?)…for a second, then I said “kidding”.

So basically in a month I should be able to participate in my regular activities. Yippee!!

I need to race Ross down to the bottom of the Grand Canyon!

Still, based on, say, a 9-month marathon, I’m at mile 6.7.

Posted by: johnskier | March 30, 2008

Back from vacation…

Man…I’ve missed a lot on the achilles blogs…trying to catch up.

I have a few things to report and thought a post would be most appropriate.

Where were we? On a cruise out of New Orleans (Norwegian Cruise Line)…4 stops - Honduras (Roatan), Guatemala, Belize and Cozumel.

Do you know how long cruise ships are? I think about 900 feet…and it’s easy go go up to, say, the main dining room when your cabin and the dining room are both aft and there are elevators. But to go 300 feet or so to mid ship, then up to the pool or to the fitness area or to the bar…well that’s more work.

The good news is that 2 days before I left my doctor said I could be 50% WB in the Aircast (that’s 5 weeks from surgery). Thank goodness…that was incredibly helpful and I felt confident moving around the ship…clearly much stronger on the crutches than the first 3 or 4 weeks. So I continued to take the foot out of the Aircast, do ROM work, and just relax.

The other good news is my PA made me a splint and I got a Dry Pro cast bag. I got a large, 1/2 length and it fit over the splint and ace bandage. It sealed very well and was able to snorkel in the Belize Great Barrier Reef. Pretty cool, although at one point a storm came through and the waves were pretty big and all of us were paddling like crazy. But I only had a fin on my good foot. I was exhausted by the time we got back to the boat. I did have to put weight on the bad foot to get back in the boat but used my arms to pull me up and made sure the weight was not on the front part of the foot (in case the splint didn’t support my weight).

What else? These other countries don’t have the Americans With Disabilities Act so it’s a bit more interesting to get around. Wheel chairs would be very challenging in these places.

Other adventures: going to a school for local Mayan children in Guatamala. A really great experience…up the river in a boat, then crutching from the boat up the ramp maybe 100 yards.

What to avoid on a cruise (and I did)? Getting drunk and falling down the stairs.

The trip further supported that getting back to normal as much as possible is the way to go.

Sorry to see so many have joined the “club” but looks like Dennis, Brendan, Tom, Doc Ross, Leeisme, Nancy, etc have continued to be very active. Looks great.

Posted by: johnskier | March 22, 2008

Vacation survival kit for ATR patients…

So we're leaving for spring break and I think I have everything I need...see below.

Aircast, book, sandal for the good foot, sunscreen, beer, splint and ace bandage, hat, snorkel gear, swimming suit, crutches. I actually forgot to put my Dry Pro boot in the picture. It's a rubber boot that has a pump that sucks all the air out so you have a seal around your leg. I'll let you know how it works. It won't fit over the Aircast so I asked the doctor if I could snorkel with a splint under the Dry Pro. They were nice enough to make a splint for me.

It's 5 weeks post op and I'm 50% WB so we'll see how it goes, trudging through airports, etc...

So if I'm not available the next 9 days...well...I have an excused absence. Cheers - take care of yourselves.

John

survival-kit.JPG

Posted by: johnskier | March 20, 2008

5 week check up…

Incision: Looks really good, healing well.
Tendon: healing well. The “lumps” are normal, will probably always be there (lumpy where the two ends were sutured.
PWB: 50% PWB in the Aircast with crutches for 2 weeks (week 5 to week 7 post op)
FWB: After two more weeks (7 weeks cumulative) without crutches in the boot.
Movement: Move my foot around in circles, like I’m using my big toe to write on a piece of paper. Can pretend I’m writing in upper case, lower case, different letters, etc. Up, down, around etc. Only do what my own muscles will do. Do not apply external pressure with my hand to increase ROM.
After 4 more weeks, I go back and then PT.
Snorkeling on our spring break trip: Yes is ok. Yes I can use the Dry Pro boot. Does it fit over the Aircast? No. Okay, a splint will be ok (on three sides, with ace bandage). My PA made one for me…I am very happy about this and thanked her (several times).
Blog tip: The heel lifts are there for a reason. I had taken out one (1/4 inch?) because it was really bugging me with my heel so high. So don’t take any of the heel lifts out of the boot without your doc telling you to do it. He said “we had it that high for a reason” and doesn’t want me to take any more out. I could tell he was irritated with me. Oops. But it’s healing great and all’s ok.

I’ll post a picture later of the incision.

Posted by: johnskier | March 17, 2008

Conversation with my 11-year old son…

I’m going to paraphrase a real conversation I had with my 11-year old son:

“Dad, why did you have to go skiing that day? You injured your achilles tendon, and now you’re on crutches…..”.

“Well”, I said “I could have been sitting around getting fat and watching TV”. That doesn’t seem so good. And then I could get hurt stepping off of the curb. And I love to ski. I’ve skied for long time, so I’m not just going to not go because I might get hurt”.

“But Dad”, he said, “you got hurt that day, why’d you have to go? I had a bad feeling…”

“That’s the way it is sometimes. I didn’t want to get hurt”. A change in tactic: “So I’m thinking maybe you shouldn’t go to basketball practice tonight. You might twist your ankle or jam your finger. I think you should stay home. You could get hurt.”

“But Dad, I love basketball. It’s fun.”

“It is fun. I love basketball too. Okay, so maybe it’s good to do what you really love to do. Sometimes you will get hurt. That’s the risk you take.”

“Okay, I think I get what you’re saying”

True story as best I recall.

Posted by: johnskier | March 16, 2008

Operative Report - 2/16/08

OPERATIVE REPORT 

PATIENT: XXXXXX

REC:  XXXXXX 

PROCEDURE DATE: 02/16/2008  

PREOPERATIVE DIAGNOSIS:  Complete rupture of the left Achilles tendon. POSTOPERATIVE DIAGNOSIS:  Complete rupture of the left Achilles tendon. OPERATIVE PROCEDURE:  Left Achilles tendon repair. SURGEON:  XXXXXX ASSISTANT:  XXXXXX ANESTHESIA:  General LMA with preoperative popliteal block. COMPLICATIONS:  None. TOURNIQUET TIME:  Under 1 hour. REPAIR UTILIZATION:  FiberWire suture. PROCEDURE:  The patient received 2 g of cefazolin in the preoperative holdingarea.  Additionally, he received a popliteal nerve block from the anesthesia department.  He was brought to the operating room and placed in the supineposition on the operating table.  General anesthesia was induced.  He was then placed in the prone position and scrupulous attention was paid towards patient positioning.  There was a pre-prep done with isopropyl alcohol and then a formal prep and drape was done with chlorhexidine.  Draping was done with scrupulous attention paid toward sterile technique.  A posterior incision was marked on the region of the posterior medial border of the Achilles tendon. Esmarch exsanguination was utilized.  The tourniquet was inflated to 250 mmHg.  Sharp, blunt, and electrocautery dissection was taken down through the skin and soft tissues directly to the peritenon.  The incision was taken just medial to the medial border of the Achilles tendon in an attempt to minimize disruption of the sural nerve.  The peritenon was fully ruptured in the region of the rupture and was ruptured distally.  The most distal aspect of the insertion of the Achilles tendon on its most distal half was intact and the more proximal aspect of the peritenon was intact and this was split in line with its fibers and preserved for further repair.  Copious irrigation was done throughout the entire region.  The tendon was extremely frayed, however, the frayed ends were preserved.  The popliteus tendon was had been ruptured in a much more proximal location and remained attached at its more distal insertion of the calcaneus and this was preserved for further use.  After copious irrigation and a minimal amount of soft tissue dissection, the proximal and distal ends of the tendon were whipstitched with two FiberWire sutures proximally and two sutures distally.  The ends were tagged for further repair. The ankle was then placed in maximal dorsiflexion and plantar flexion.  After evaluating range of motion, it was placed into plantar flexion for tying of the repair.  The repair was then tied with the ankle in approximately 20degrees of plantar flexion which did not create any tension.  The FiberWire sutures had excellent fixation, fit, and purchase. The foot remained in plantar flexion.  Excess frayed portions were then reapproximated in an attempt to drape over the repair.  The length of the plantaris tendon was then taken from its distal attachment where it was preserved and then woven through the distal and proximal segments and then draped over the proximal segment and fixed with 0 Vicryl suture.  Again, copious irrigation was conducted. The peritenon was then reapproximated with 0 Vicryl suture in an interrupted manner from distal to proximal and from proximal to distal.  There was acomplete lack of peritenon in the region of the rupture, however, this was approximated as best as possible.  Following this repair, the tourniquet was released.  Hemostasis was attained and a layered closure was done on the skin and soft tissues with 2-0 Vicryl suture and nylon interrupted suture.  Dry sterile dressing was applied.  The foot was splinted in plantar flexion and the patient was awakened, extubated and brought to recovery room in satisfactory condition having tolerated the procedure without difficulty. 

Posted by: johnskier | March 13, 2008

Survival of the fittest…

Somebody made a comment about natural selection in their blog.  It got me thinking about the consequences of an ATR under different circumstances. 

I went to www.Youtube.com  and entered something about achilles tendon rupture.  I found a video of a water buffalo that apparently had an ATR (caused by a lion who apparently went after its AT).  Well…the water buffalo in the video is alive and the lion is chewing on its hind quarter.  The water buffalo is doomed.  I couldn’t watch for long.  Not good for the water buffalo.  Good for the lion.

Okay…then I had a conversation last week with the local dog trainer (Mark).  I said…”geez…don’t canines go after their prey’s achilles?”  “Yes they do”, Mark said.  In fact when I was a kid I (John) actually saw an Australian Shepherd down a deer by going after its tendon on the back of its leg.  Not good for the deer.  Good for the canine.

Then I was thinking…what if you were a nomad, a hunter gatherer? Let’s say you and your clan (I’ll call it a clan) were trying to run a herd of Buffalos off a cliff to kill them so you could harvest them…eat them, get their furs, horns, etc.  That’s a good idea.  That’s what they did.  Good idea until you rupture your AT.  What does your clan do?  Maybe you could create a cast of sorts and then you hobble around until it heals naturally.  The “non-surgical” technique referred to in journals (ha!).  Maybe you can aid healing using some concoction created by the clan’s healer.  Maybe you get to PWB very quickly (double ha!!)  But what if winter’s approaching and the buffalo have been harvested and the clan needs to leave for a warmer winter location?  You can’t risk the lives of the entire clan by holding them up.  Well…I think you get left behind with the wolves.  Not good for you.  Good for the wolves.

There are all sorts of really bad circumstances that indicate that a ruptured achilles tendon means that you are not the “fittest” and therefore you don’t survive….Darwinism in action.  (Okay…don’t get depressed, I have a good conclusion).

So are we modern ATR “victims” actually surviving past our intended or perhaps probable life span?  My answer is no, because…we’re SMART ENOUGH to get the best possible medical care, use the internet and this BLOG to gather the best possible information about treatment, nutrition, etc., then we use our BRAINS to combine all of these elements into a program so that we are stronger and better than before.  

And that my friends is survival of the fittest!!  (hope this wasn’t too morbid)

Posted by: johnskier | March 9, 2008

Day 22 post op

Here are a few more pics:

1.  Crutches.  The spikes are down (for ice) one one crutch and up on the other for normal conditions.

crutches.JPG

2.  Incision 22 days post op.  I noticed that the skin is separated a bit near the top.  You can see the “sterile superglue” starting to peel away.

 incision-day-22.JPG

3.  Aircast.  See the valves to pump it up.  four different bladders (front, 2 sides and back) 

 aircast-2.JPG

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