12 weeks post-op - Milestones and running

So, had my 12 weeks (strictly speaking that would be tomorrow) check-up today with the physio, and my OS popped by to check in as well. Following my OS having a quick discussion with the physio and a check of the scar, I have now been officially released by him to the care of my physio for the remainder of the recovery.

Happy to report that I’ve now managed to build back some muscle in the calf, exactly 0.5cm at the widest point (circumference) compared to the previous measurement. The difference to the healthy leg is still significant and noticeable (1.2cm on the measurement), but moving in the right direction. All the rotations and plantar/dorsiflex ROM is equal to the healthy leg, both with open chain and closed chain (understand the latter typically recovers a little later when you can start stretching, you can test by seeing how far you can have your foot from the wall and still push you knee to the wall while keeping your heel on the ground).

Otherwise went through an escalation on the physio exercises, the specific rehab work now involves heel raises standing on an edge of a step (starting from negative), initially with going up with two feet and coming down on one, and in the next couple of weeks moving toward single leg. Also standing heel raises with knees bent leaning on knees (escalation of sitting heel raise), as well as a couple of different squats (with weight encouraged) and balance work (on balance board, bosu-ball etc). Finally tried out running on a treadmill for 5min (with slow pace), and it worked well, according to her my step was effectively normal and it felt perfectly fine. So I’m now also cleared to start running on the treadmill, initially with 5min run, 5min walk, 5min run etc, and building up from there. Outside of the specific rehab exercises, I’m cleared to do most things (including rowing now that the closed chain rom is good), apart from things involving jumping and similar explosive moves.

So very happy with the progress, especially getting back to running feels exciting!

Finally, inspired by Donna, here are the milestones of my ATR recovery so far:

- 20 Oct 2014 – Full rupture of AT (and plantaris tendon) playing basketball. Quickly diagnosed and put in a splint to await surgery.

- Surgery 3 days later – Done under spinal block, standard surgery with the addition of the Lynn technique (plantaris tendon used as “cover” for AT repair). Foot put in plaster cast, set at nearly 90 degrees.

- 2 weeks post-op – Stitches taken out, moved to Aircast boot with no heel lifts, and directly to FWB (within the day, didn’t use crutches since). Also started PT with some simple exercises three times a day.

- 4 weeks post-op – Second physio, added some resistance to the exercises with a theraband etc.

- 6 weeks post-op – Moved to two shoes, for the first week avoiding strong push from ball of the foot. Physio expanded to involve squatting, stationary bike etc.

- 9 weeks post-op – Walking getting to normal with a normal push, added training on elliptical to workouts

- 12 weeks post-op – Released by OS to care of physio for rest of recovery. ROM completely normal, can manage a (kind of) single leg heel raise, cleared for running on treadmill and most other activity apart from jumping etc.

That’s it up to today, in hindsight it feels like the first 12 weeks have actually gone by fairly quickly, and I’m very happy with the progress so far.

11 weeks post-op - Moving along

Just a very brief update this week, as not that much has happened, will try to update a bit more next week (and also include my milestones following Donna’s example) when I’ve had my 12 week check-up.

Things continue to move along incrementally, I’m starting to see some proper muscle definition in the injured calf, and the strength is slowly returning. I’ve continued to follow the physio protocol, I’m sure I’ve never done anywhere near this much work on my calfs before… On the heel raises, I have continued to incrementally increase loading towards the injured foot, which is managing it better and better. I can (kind of) do a single leg heel raise on the injured foot now, I can get my heel off the ground, and when going up with two feet, I can hold myself up with the one leg, but starting from the bottom I can’t get myself all the way up with one leg. Based on recent progress, I expect that will happen in the next week or so hopefully. One point here to everyone doing these is to focus on the eccentric contraction (i.e. coming down slowly, rather than just up-down quickly), this has really helped me build strength. I’ve also continued with the cardio on bike and elliptical as before.

Otherwise walking is completely normal now (although at times still need to think about it a bit more), I’m back to walking to work now that I’m back from holiday, so getting a bit of pure walking in that way everyday as well (about 1.5km each way). Looking forward to my appointment with physio and OS next week, if there are no issues (as I don’t think at the moment that there will be), it should be the last one with the OS, who will release me to the care of the physio from there on…

And here is once again a picture of the scar today, at 11 weeks:
11 Weeks

10 weeks post-op - Towards a new year

So, it’s been another week, and I feel like I continue to make progress. I’ve started to walk at my normal pace and stride with a normal push-off during the last week. Sometimes (first thing in the morning etc) I still have a bit of a limp until the foot warms up a bit, but other than that walking is completely normal. I’ve also transferred to using my normal “minimalist” shoes for longer walks instead of more traditional sneakers, and that is working well. Also going up and down stairs more normally now, although not fully loading my weight on the front of the foot yet.

It’s also gotten better with the workouts, I’m now doing up to an hour on the elliptical or the bike, with no pain or strain. I still use a higher rpm rather than a higher resistance for the longer runs, but comfortable doing an hour with an avg HR ~155 with no problems. I’ve started to also mix in some more interval-type training with higher resistance periods mixed in. I’ve been going to the gym twice a day on most days, with a longer work out in the morning and more strength focused stuff in the evenings. The physio protocol of heel raises etc I do twice a day. I’ve started increasing weight on the heel raises more toward the injured side on the slow descent specifically, and I can feel it is slowly getting stronger, but still a ways off from doing a single raise. The calf visually looks better as well, with some muscle definition starting to come back, and the swelling around the tendon seems fairly limited (probably what it will look like for a long time).

So it’s been a happy week, I have been tempted by the treadmill a few times just to try it out, but have decided to hold on that until the next physio in two weeks, no point in doing something stupid now. Generally I feel like I’ve gotten to a good point in ten weeks, and can start the new year feeling like a normal fully functional person again, even if the road to truly being fully functional is still a long one.

Happy New Year to everyone!

EDIT: Finally got around to adding the photo of the current state of the scar as well. So this is a week earlier at 9 weeks.
9 Weeks

9 weeks post-op - Progress (slowly)

Been two weeks since I posted last, didn’t really get to it in the pre-holidays hassle. But things have continued to be generally good with no significant issues. Progress is noticeable, but painfully slow, I’ve come to appreciate the term “frustrating plateau” :)

I’m now 9 weeks post-op, and three weeks into two-shoes. Walking has gotten gradually better, almost at a normal stride now. I naturally have a fairly long stride and I’m a fast walker, so not quite up to that level yet, but walking with a more conservative stride happens without a really noticeable limp now (depending a bit on the time of day and what I’ve been doing). I’ve been somewhat religious about the rehabbing and trying to really build strength in the leg. Basically my standard routine is the one I included in my previous post, but I’ve added some time on a stationary bike as well (more for cardio than necessarily building strength). I can comfortably now do about 45 minutes on the bike without issues, noting that the longer runs especially I do with low resistance and a higher rpm (EDIT: I’ve now today also added the elliptical to my repertoire, 30min no problems, but a pretty “flat-footed” approach). Also a lot of heel raises and squatting as well, two-footed heel raises are no problem with weight evenly distributed, I do 3×15 twice a day at the moment, and the same with seated heel raises leaning on my knees for weight. Generally it feels very good to be back to doing cardio that really makes you sweat, mentally that has been important. ROM also continues to get closer to the healthy foot, no tightness in foot when e.g. squatting below parallel, getting back to the usual point where my hip flexors are the main issue in really squatting ATG :)

Otherwise it’s a bit of a strange period, I feel that (apart from exercise) I feel close to being fully functional in terms of everyday life, but the jump from here to being really fully functional is a long one. Sometimes I think that there is no progress, but then I think a week back and realise that there is progress, even if it isn’t the “big steps” of moving to FWB, two-shoes etc. At the same time, I’m painfully aware that I’m just hitting the peak period for re-ruptures, so I don’t want to push too much until I hit the ~12 week mark…

Decided to also transfer my rehab to a warmer climate for a couple of weeks, and took off to Thailand. Actually this was originally meant to be a golfing trip, but now I can focus on my rehabbing instead. Two days in, it has been great, no freezing snow to worry about, walking around bare foot, and just combining easy lounging with long gym sessions without a rush to be anywhere :)

Finally, I’ve been reading a number of the new stories on this site, and really come to appreciate my OS, his approach to rehab and recovery. When there is no evidence of a longer casted period or longer NWB/PWB period having any benefit (mostly the opposite, within limits), I think I would’ve gone mental spending a long time on crutches especially (the boot was manageable FWB). Also now that I have a better appreciation for what that muscle atrophy actually means in terms of strength (not just visually), I have become a believer in minimising that with early FWB and physio. I commend the people for enduring 10 weeks in a cast / PWB, but at the same time I know that knowing what I know now about the studies and protocols, it would’ve been difficult to take. Even if the results (for surgical) even out in the long run, the difference in quality of life is huge for that time period… (/end rant)

I wish everyone a great holiday period, stay safe and recover!

7 weeks post-op - Mixed week

Well, it has been a week of mixed feelings. Went to two shoes a week ago, and the first couple of days were, in a word, frustrating. Moving from walking around very comfortably and quickly in the boot, going to fairly tender and slow walking was a bit challenging. Even knowing that it is good progress, it felt almost like a step backward, certainly in terms of mobility. After a cozy four weeks in the boot it was definitely a wake-up call for how long this process is, and how early it still is for me.

Anyway, once I got over that, I got back to work. I’ve been walking quite a bit now, and it is actually getting better by the day. I’m still not really pushing off the front of the foot properly, but it’s close. I find that I need to actually concentrate on walking in order to walk more properly, if I don’t I have a more pronounced limp. When I concentrate, I can walk almost without any limp at all, especially barefoot (for some reason I find it more difficult in shoes for now, might be the pressure on the tendon). In the last couple of days I’ve actually been happy with the progress again, as I’m getting closer to walking around at normal speed, and there has been no pain or swelling at all throughout the process. So for those who are struggling a bit the first days in two shoes, don’t let it put you down, you’ll get used to it quickly.

Finally, had another physio appointment today, and she was again very happy with the progress. Should maybe be noted that I don’t go to a physio to actually do the workouts, I go to check on progress and go through the next set of exercises that I then do on my own. In addition to the basic ROM and atrophy follow-ups, did a test on how far from a wall I can stand flatfooted and push my knee to the wall, managed to have my toes 9cm from the wall (compared to 14cm on the healthy side), which was actually better than I expected. Also tested how well I could squat and a couple of similar things, all of which was actually surprisingly good compared to my expectations. Then we went through my new rehab routine, which I’m supposed to do daily. In case someone is interested, it now involves:
1. Back squats, not below parallel for two weeks, allowed some small weight
2. Split squats, with back foot on bench, some small weight allowed as well
3. Standing two foot heel raises, initially with part of weight on table etc support
4. Sitting heel raises, leaning on knees for weight
5. Toe raises leaning back to wall
6. Balance exercises, standing on one foot etc
7. Three different stretches (two more for calf, one for tendon)

This new routine made me very happy, as it is starting to feel more like real exercise and strengthening the muscle, rather than just maintaining mobility.

So in summary, after a somewhat frustrating start to the week, I feel like I’m back up to speed and on track again!

6 weeks post-op - Two shoes

Had my 6 week post-op check up with the surgeon this morning, and progress has continued to be good. He started by checking the tendon and the scar, and was happy with both, the tendon is clearly continuously there as it should be, with no significant bumps etc. Scar has also continued to heal well, so no issues there, got some instructions on rubbing the scar in a certain way, in order to maintain movement between the tendon and the skin and prevent scar tissue build up. Generally the swelling around the area is according to him as expected, but actually fairly limited.

Moved on to checking ROM, which he thought was very good for six weeks (I have only a very slight difference on the dorsiflexion compared to the healthy foot at this point, barely noticeable). Finally he had me test a couple of two foot heel raises, which I managed fairly ok, although the strength in the injured foot is clearly somewhat pathetic. Calf atrophy is clear, but he said that he has seen much worse as well. In the end he cleared me to move to two shoes from the boot. I’m meant to walk with a “normal” gait, and roll the foot to the toes as normal, but just leave out the final push from the injured foot for the first week or so, depending on how comfortable I feel. In addition, I was cleared to start some other activities (swimming, stationary bike, squatting with minimal weight, etc), basically the instruction was to not do anything that causes pain, but otherwise fairly liberal. He was also very clear in pointing out that although my progress has been good so far, that as I now don’t have a constant reminder of the boot on, to be careful and bear in mind that it’s still early on in a long process. The expectation now is that if there are no setbacks and progress continues to be good, at 12 weeks I should be able to start running on a treadmill and incorporate some heavy resistance work for the calf to properly recover strength, which sounds very positive to me.

Also had a brief discussion with him about the differing protocols for treatment. He basically said that he prefers the fairly quick transfer from cast to FWB and from boot to two shoes primarily as he believes that (in addition to the easier life for the patient), it obviously helps reduce the muscle atrophy and losing strength in the leg. This in his view helps recover quicker to normal activity, as after the initial 10-12 week period it is the lack of strength rather than the tendon itself that is the main challenge, and as much as that can be avoided early on, the easier the recovery. For him the only benefit of longer periods in cast / boot is to protect the patient from themselves (i.e. not being careful enough).

I’ve now been walking in shoes during the day, and it is actually going pretty well. Clearly my stride isn’t really normal, but I am able to roll through the injured foot without any pain or without feeling like it is stretching the tendon. Walking is still slower than it was with the boot though, but it’s not crawling at a snails pace, hopefully as I get more comfortable and start getting used to this, I will be able to get back to normal walking fairly soon. Will during the first week at least use the boot though in higher risk environments, like when heading out for a few beers tonight to celebrate my freedom from the boot (while wearing the boot) :)

4 weeks post-op - Physio #2

So, had my second physio appointment today with no real surprises, seem to be making good progress. Scar has continued to heal nicely, she thought it looked very good for four weeks, which sounds nice. She did the Thompson test and a couple of other things to check the tendon, and all is as it should be there. No swelling present at all in the ankle, measurements around the ankle were an exact match to the healthy foot. Calf atrophy on the other hand is pretty noticeable, circumference difference is little over 1cm, which sounds surprisingly little compared to the visible difference to the healthy leg. ROM was also good, no difference to healthy leg in plantar flexion, and only a slight difference in dorsiflexion (would say about 10 degrees or so). According to her I’m well on track to get rid of the boot in accordance with the planned timetable in two weeks, 6 weeks post-op.

Got some new rehab exercises, now incorporating a resistance band for some of the movements. Exercises still mostly consist of plantar/dorsiflexion, different “sideways” rolls, toe curls etc. She stressed the importance of the other movements beyond just the straight flexions for stabilization when moving into two shoes away from the boot, and for maintaining the arch of the foot normally at that point as well. Feels good to be adding some resistance to the movements, not exactly strength training for the calf, but at least moving more towards at least stopping further atrophy. Considering how my calf now looks after four weeks, can’t imagine folks that are in a cast for eight weeks without any movement and how that would impact the muscle.

Otherwise been rolling along comfortably, walking in the boot comes pretty naturally at this point, and I have a steady walk rather than a limp as such. Have been covering also some slightly longer distances now, the only issue for me is that the heel gets a little sore after some time, but that stops immediately when I take a break from walking. At home I spend most of the time without the boot, I’ve been given an ok to carefully walk around the short distances at home without the boot, just making sure that I keep the weight on the heel when doing that. Generally I feel like the initial month following the surgery has actually gone by fairly quickly, and progress has been constant and noticeable. That also makes me think that I need to now adjust my mentality somewhat, I need to settle in for the long haul of recovery and accept that progress will be relatively slower and the increments smaller (which isn’t saying I’m accepting a slow recovery). Otherwise I can see myself getting frustrated very soon :)

Here is also the mandatory scar update, so at 4 weeks + 1 day:


As I’ve now finally figured out at least one way of adding photos, I will add all of them here in a new post, and then on an ongoing basis add them to the posts.

Surgery photo, the “white” thing is my plantaris tendon, which has been spread over the achilles’ after its been fixed, to provide a smoother surface.

Two photos from the when the cast came off after two weeks. The first immediately after the cast came off with the stitches still there. The other after they’d taken the stitches out and added a piece of tape as cover.
With Stitches
Stitches Out

And finally the photo from a few days ago, about 2.5 weeks after surgery, when I first took off the tape that had been there after the stitch removal.
2.5 weeks post-op

EDIT: Here is one additional photo, this is what the scar looks like right now, at 3 weeks and 4 days post.op
3-4 post-op

3 weeks post-op - Back in the office

Ok, a few days late, but Thursday was three weeks from the operation. Fairly uneventful week actually, but healing seems to continue to progress well. Went back to the office on Monday (had been working for home for two weeks), and really no issues with the foot, main challenge is finding a working position where I can at times keep the leg elevated while not completely destroying my back or shoulders. But as the foot hasn’t been swelling up really at all in any case, it seems to work ok.

Have gotten pretty good at walking around in the boot, stride feels surprisingly natural (i.e. not limping / gimpy) once I got the hang of it. Took me a day or so to learn how to roll the boot from heel to toe, the key for me was thinking about pushing with the shin against the boot (just mentally, not necessarily a strong movement as such). I think the difficulty comes from everyone naturally wanting to put weight on the toe of their foot when walking, which you obviously can’t do in the boot. So maybe that is helpful for some people who are struggling with the technique of walking with the boot: don’t lock your knee, and think about forcing the boot to roll from heel to toe by pushing your shin forward.

The only issue I’ve had with walking with the boot is that when I’ve gone longer distances, it seems to put more stress on your heel compared to normal walking. So yesterday when I was travelling and had to walk fairly long distanced through airports, the heel got a bit sore during the walking, but it went away immediately when I took a little break. No swelling etc as a result of the walking either so far.

Have also spent quite a bit of time with the boot off, both when sitting at my desk in the office, as well as home. Feels good to have the boot off once in a while, and allows me to do some of the physio-prescribed exercises over the course of the day as well. So all in all everything is progressing as well as it can be I guess, looking forward to my next physio next week to hear what she has to say and what I can add to my rehab exercises.

Here is also a picture of the leg, this is from 2.5 weeks after the surgery, the firs time I took off the tape they put on when they took away the stitches. Actually looks better now.

2.5 weeks from surgery

EDIT: Noted I’ve just also made it into Brooklyn in the marathon tracker, at least I’m off that bridge :)
EDIT2: Finally figured out the photos

2 Weeks post-op – Hello boot and FWB

Had my first appointment after the surgery today. Got the cast and stitches off, the scar was actually cleaner than I had anticipated, and there was effectively no swelling at all. To be honest, I’m not actually bothered about the scar in terms of looks at all, as long as it heals ok I’m happy. Should be noted that I have been able to have the leg up very strictly during the first two weeks, so that has possibly helped quite a bit. Stitches also came out easy, was told to possibly expect some fluid leakage in the next few days, but otherwise they were happy with how the scar looked (I do have photos as well, but still haven’t been able to figure out how to add them to the post).

Also had my first physio appointment at the same time, she tested the movement and had me do some short exercises to see what was happening. Everything was working well, and I had no problem having the foot at the 90 degree angle for the boot. She also took some measurements to follow progress over time, right now the injured calf was 1cm less around compared to the healthy leg (at the thickest point), but impossible to tell how much I have lost in the last two weeks as there is no starting reference. You can tell there’s a difference looking at the calves, but so far the difference isn’t massive. Got some exercises to do three times a day for the next two weeks (until the next physio), basically ankle flexion-extensions, rolling foot side to side, toe curls and a few other similar things. We discussed that we’d include resistance to the movements the next time.

Finally, I got fitted for the aircast walking boot, set directly at 90 degrees (no heel lift). No significant tightness at that angle, and the boot feels pretty comfortable (at least so far). I’m supposed to go full weight bearing right away as much as I can, and only use crutches if I start getting pain from walking without them or I want to use them for additional support for specific situations etc. I have now for a couple of hours been walking around the house without crutches and haven’t had any problems or any pain. All-in-all, so far everything seems to be moving along as well as it can be, and the additional freedom from moving around without crutches is a big lift mentally.

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