Surgery … FHL tendon transfer?

Hi all -

In late 2010 I ruptured my left achilles tendon playing basketball.  I had surgery to remove a bone spur, reattach the achilles to the bone, and some debridement. Surgery was successful and recovery was great.  I returned to basketball about 9 months later.  On 1/9/2014 I had surgery to remove a bone spur and debridement of the achilles tendon on my right foot.  Unfortunately, it has not healed and I am in quite a bit of pain.  The followup MRI confirmed that the tendinosis remains.  I had a PRP injection June 2014 but that did not have any effect.  My doctor is now recommending a FHL tendon transfer to augment/reinforce the achilles tendon.  I got a second opinion and that Dr. said to have Cortisone injections but everything I have read said that that is not the right thing to do.

I am looking for feedback from anyone who has had the FHL tendon transfer.  I am 35 years old and from what I see this surgery is mainly done on people over > 50 years old.  For those of you that have had it, how has recovery been and what is the functionality like after?  The Dr. said that I would regain all functionality and that the only impact would be that I could not curl my big toe but that I wouldn’t even notice.

Thanks in advance for the help!

29 Responses to “Surgery … FHL tendon transfer?”

  1. Hello all, I was wondering what it feels like the following days after the boot comes off. I get my boot off August 7th and my dad was planning a trip for around August 12th but im not sure how sore I will be a couple days walking in two shoes. Any input would be appreciated.

  2. Hello again Greg. Similar question as before so I guess the trip to Europe is still on. You are about 9 weeks and given you will be in a boot until 11 weeks it seems your doctor is putting on the slower path to two shoes. You haven’t given us much information about what you have been doing in the last 9 weeks so it is a bit hard to know how much (yes how much) it will hurt if you have to do a lot of walking on this trip. Are you weight bearing in the boot or still using crutches? Have you walked around home in shoes without crutches? There are probably many more questions but it seems you want to go on the trip. Take the boot with you. Be prepared to rest, elevate and ice. Make sure you have good travel insurance and pain killers. Personally I found a couple of wedges under the heel of your shoe helps to take the pressure of the tendon. Wear good supportive shoes and even up the other shoe with wedges if you can. You should have a PT by now but if not get one and ask some questions of them about how best to prepare for the trip and stay safe. Hope you have a great time. Be careful of your step.

  3. @Justin, I don’t have much. Search the site for fhl etc. and you’ll find lots of folks here - mostly ATR repairs - who’ve had it. Isn’t that what Beckham and a number of other elite athletes got post-ATR?
    Not sure what you mean by “hasn’t healed”, but I think I’d get at least one other expert opinion before going back under the same knife with the same OS.

    @Greg B: Have you removed your boot at all yet? PT, exercise, standing, maybe a little walking? Most good protocols hit “wean off boot” around 8 weeks post whatever. Early 2 shoes is usually scary, tentative, and slow, as you can read on every single blog that’s gone that far. That’s why weaning is way smarter than going cold turkey.

  4. Justin - I did not have this surgery but understand they use the tendon from the big toe. There have been quite a few people through here who have had it done and have healed fine. They may still be visiting the pages and see your question but it may be up to you to find them by reading the blogs individually. That will take some time I know. I would definitely not go with the doc who suggested a cortisone injection as this shows a greater lack of knowledge. You could also investigate LARS as an alternative to tendon transfer. It is primarily used for ACL’s but can be used for tendons as well. Have a read here for more info
    The company may be able to put you in contact with a doctor who uses it. I have not read of any person here who had a LARS treatment so I cannot vouch for it but from what I have read it seems to work well. Early versions had some issues with tissue rejection and wound healing but that has been resolved I believe. It would be a good question to ask regardless.

  5. Justin,
    I had surgery for insertional tendinosis, Haglund’s excision, and removal of some spurring. My surgeon was going to use cadaver tendon if he had to debride more than 50% of my tendon. (He removed less than 50%, so no augmentation was needed.) When I asked why he wouldn’t be doing a FHL transfer, he said that, as a runner, I would definitely notice the absence of my FHL and it was not ideal; the recovery would be longer and more complicated, AND, the FHL transfer was more something they did in the past. As you’ve already read, every surgeon has a different opinion. You may, however, want to ask about other options and DEFINITELY get a second opinion.

  6. Every surgeon has a diffent opinion, and around 3% of those opinions are supported by the evidence!

  7. Thanks everyone. @norm - I did the debridement and the Dr. had to remove <50% of the tendon so no augmentation was needed. However, 7 months down the road I still have thickening of the tendon and in a quite a bit of pain. MRI confirmed secondary tendonosis.

  8. @justinw, does “I still have thickening of the tendon” just mean that your AT on that side is obviously thicker than the other one? If so, I don’t think that’s worth mentioning at 7 months, but “in a quite a bit of pain” certainly is. I had a full month of quite a bit of pain after a few minutes of overdoing (during a PT session!) during my first ATR rehab. Pain tells us that there’s something wrong, but it often doesn’t tell us what.

  9. I have been in physical therapy for 3 weeks and I’m FWB. Whenever I walk long distances it begins to swell up but I ice throughout the day. My doctor has me on the more conservative approach but I feel I would be able to walk in two shoes now. I just don’t want to go away 3 days after I get my boot off and be in a lot of pain from the walking

  10. Greg - I feel you really want to go on this trip and are a bit anguished. Norm has given you some good advice but the decisions to be made are really yours. Why not discuss all this with your PT and father then start a transition to shoes now. You could be doing it in a safer environment and then maybe you will be able to answer your questions based on real experience. I agree that 3 days in shoes before leaving would be too soon. Take the boot on the trip regardless. If you have a problem you could put it back on. Weigh up how much this trip is worth. I am sure you don’t want to miss out but a slip or fall could put you back to the start. How much will you be trying to keep up with the others and neglecting your healing tendon? Given the conservative approach your doctor has taken I believe the risks are high but you have a few weeks to turn things around or clarify your position.

  11. I had an FHL transfer on 6/17/2015. I am 53 yrs of age. The rgt Achilles tendon ruptured due to degeneration and calcification of an old lawn mower injury at the site of the rupture.

    I was literally bed ridden for 4 weeks. The first two weeks were miserable. Pain meds made me very sick, so I decided to tough out the pain and drop the meds and use them only when necessary.

    I was in a splint for the 1st two weeks. Then, a fiberglass cast for 1 week (they put it on too tight and it turned my toes purple). Had that one cut off. A PA put another one on but she had my toes pointed down too far, so they cut that one off and put me in another split with probably a 20-30% plantarflexion. I could not get to neutral. I stayed in that splint for 2 more weeks.

    At week 5, I was put in walking boot but told no weight bearing until week 6.

    I am now in week 6. I can weight bear 25 lbs per week for the next 6 weeks, eventually full weight bear by the end of 6 weeks.

    My injured leg is very stiff. Not much movement in toes. Everything feels tight.

    Called doc. He is going to start me on physically therapy for ROM at week 7.

    It has been a long hard road so far. I battle with depression, anger, frustration.

    I was very active before the injury and to come to a dead stop is pretty mind numbing.

    I have a business to run and can’t run it like I used to.

    Struggling to keep it all together.

    I wish the doctors would give us more information on the protocols–road map so to speak.

    Even information on how to care for the unaffected limbs. My left leg is taking a lot of abuse right now. My arms hurt from the crutches. My back muscles are so tight from laying in bed and being contorted on the knee scooter.

    I am better than I was 6 weeks ago. I hope this new weight bearing schedule and PT gets things moving a little faster.

    I certainly to not want a re-reputure, so I am following the doctors very conservative approach.

    He mentioned to me that he did a lot of surgery and this was not just and “ordinary” stitch two ends of a severed Achilles.

    I do not wear the boot in bed but I must wear it when I am not in bed.

    The swelling is ridiculous. My enemy. Every night, I am in bed at 6 pm icing down. I stay there until I fall asleep.

    I have not had a good night sleep since June 7 (date of rupture).

    I was put on a medicine called neuronton for the stabbing, stinging, burning pain in weeks 1-4. I was told that this was nerve pain. The neuronton is now making me forget things. It plays with your memory bank. I am about to cut that off because my job is cerebral.

    Does any of my story makes sense to anyone?

    Your words of wisdom would be greatly appreciated.

    I need a light!

  12. Hey mrsnooch:

    A favorite quote of mine for you to ponder:

    It could bring light if you’re open to it:

    “Change the way you look at things, and the things you look at will change” W. Dyer

    All my best to you.

  13. had ATR with FHL 10/15. spent 2 weeks in splint, 2 weeks in cast…all 4 weeks non-weight bearing. then, 4 weeks in cam walker…even slept with it on then another 4 weeks in cam w/o sleeping with it on.. Had 13 pt sessions. Still having minor swelling and gait issues. Very frustrating for sure. I’m told progression is very slow could take a year to return to normal. Disappointed that docs don’t tell you much about post surgery recovery….my experience is after surgery they lose interest.

  14. Welcome to our “club blog” Russ… We have a number of athletes here who post waht they are doing for recovery, and Beanie is our heroinne, doing crossfit at 6 months ! As she well explains, it is certainl a slow recovery process, but she and others have done their best to speed up the process within the limits of tendon healing times. As for swelling, I don’t know how many months before we can stop icing… and the gait issues seem to vary by individual.
    Please do read everyone’s posts and share your experiences, since in this club we all learn from each other.
    Good luck in your progress!………… Manny

  15. I had ATR on Sep 23 that was not successful. Infection surgery after that and finaly ATR with FHL on Dec 22 2016. I spent 2 weeks in the splint and 4 weeks in the cam walker and now regular shoe with an open back to avoid infection where the scar is. Back of my heel feels somewhat “foreign” and it my foot gets swollen after few hours of walking. I also walking with a limp. Slow recovery. hope to be able to play tennis again.

  16. Victor, what a shame you had to go through a second procedure, but at least now it sounds as if you are well on your way to recovery. You said you have open backed shoes to avoid reinfection… is the wound still open?
    As for limping, that seems to be normal as we relearn to walk and regain strength in the Achilles Tendon so our injured foot can move normally and support our weight (and that is was takes months to achieve). Are you getting Physical Therapy?

    Well, you can real all of our posts and find out a whole lot of details about different protocols, exercises, difficulties… even about gardening in CAM boot and suade shoe during a cabin fever attack! LOL
    Welcome to our group and good luck! keep us posted on your progress!

  17. I had FHL transfer six years ago because of chronic (15 years) achilles tendonosis. I was a competitive runner who wouldn’t quit.

    It is a painful and long road to recovery, don’t let anyone kid you. While I would do it again, it is not a perfect solution. My right calve is 3/4 inch smaller in spite of pretty intense efforts to strengthen and enlarge it through weights, etc. It definitely remains weaker. People sometimes ask me if I am okay, when they notice a slight “limp”. I was able to return to running, but never at the level before. I have some numbness in my heal area and it is a little weird not being able to claw with my toe. I think the other toes compensate, but my second toe is evolving into a “hammer” toe. Sometimes I wish I’d tried debridement first, but I was advised it was just as painful and did not have a very good success rate. That leaves you right back where you were, facing a second surgery.

    My advice looking back is “treat every injury as if it were cancer.” I heard another runner say this, but it was too late for me. In other words, be aggressive in treating it the minute you realize something is wrong. Finally, I had some success with prolotherapy injections on my other tendon, so consider that before going for the “nuclear” option.

    Good luck!

  18. Thanks, Chuck, for the “heads up” report on your six year process. I’m sorry you couldn’t get back to 100%.
    Welcome back to the site, though, and please continue sharing your experiences with us.

  19. Hi,
    I had an fhl transfer two years ago now, after I ruptured the Achilles, was advised to heal non-surgically and then it re-ruptured a week after I came out of boot.
    Since my surgery I can’t bend my big toe down but can pull it upwards. After I’ve been sitting/laying for a while of inactivity my ankle is normally a little stiff, consequently I have a slight limp (but this will one last a minute or so until my ankle has loosened up.
    I have managed to get back to playing tennis and squash. I used to run, and have started jogging again-am avoiding those sprint starts

  20. Hi all,

    Ok, here it goes…

    I had Achilles repair this past December, as I had Achilles tendonitis. I was casted for almost 7 weeks and then put into a boot. After a couple weeks in the boot, my doctor told me I could take it off for short periods at home and walk around. I did that, and ended up completely rupturing my Achilles. It ended up retracting high in my leg, so on April 11, I had FHL Achilles surgery and my new surgeon transferred healthy tendon from my big toe.

    Today, I had my six week follow up and because I am experiencing such severe stiffness in my ankle, he opted to put me into a boot so I can begin physical therapy.

    I’m having a lot of pain when I try to move my ankle and I’m on able to make my foot flat on the ground. I just have a couple questions for those who have experienced what I have…

    What was your course of recovery? How long were you in a cast, how long were you in a boot and when were you allowed to bear weight?

    Also, has anyone experienced incredibly debilitating stiffness in the ankle? It is just so severe that even if I am kneeling on that knee and accidentally shift or try to move my ankle, I get very sharp pain.

    Any help you guys can offer would be appreciated.


  21. Stephanie - considering the amount of time your foot has been locked up I am not surprised things are a bit stiff. There are so many little bones and ligaments that have not been moving that they will need some time and a bit of help. Your PT should be able to help you with that but given the time since you ruptured and as you are now in a boot, you can take your leg out of it and start some Active ROM exercises. Fully support your leg to your ankle so your foot can move freely. A recliner chair is good for this. Start writing the alphabet with your foot. You can do this several times throughout the day and it will help unlock all those joints. Weight bearing for this injury can start quite early. I have ready studies where it started straight after and my father had to weight bear from the start as he had other balance issues. It is generally accepted that weight bearing can start around 3 or 4 weeks so you are well past that. This does not mean you just start walking on it now. You should gradually increase the weight and work within your own pain limits. Start putting weight on it without walking and see how much you can tolerate. Walking will put a bit more stress on it. Use your crutches to support your body and take it in increments. That sharp pain you feel should go away in time but make sure you tell your therapist and doctor.

  22. @Stuart

    Thanks so much for the reply. It’s hard to find people that have gone through this or similar surgeries. I guess I’m just really scared to put any weight on it since the last time I did that, I ruptured the entire tendon. I do know that increasing my range of motion and working it out a little bit will help but I’m just scared of hurting myself again.

    The incision from the surgery is from my heel almost to my knee. It’s about 12″ long. I’m just very apprehensive because I don’t want to go through this again.

  23. Stephanie - you ruptured your tendon because the treatment offered really didn’t do anything more than rest it and it was probably so degenerated it would have gone at some stage. Once you have ruptured your body seems to change its response to healing and your tendon will in time be as strong as before but it does need the activity to make it strong. Very few people rupture the same tendon again once it has fully healed. You have to encourage the formation of aligned collagen type I which replaces the initial collagen type III which is laid down when you first ruptured. This process is called remodelling and continues for some time. If you keep the boot on and it is properly fitted then your tendon is protected from any explosive shock that could re-rupture it so weight bearing is not a problem as long as you do it as tolerated. Do not worry about the lack of flexion in your foot as it will return in time as you progress and your therapist will help you there with some things to do when the time is right. Some people get an even up sole for the other side which will also help you walk and take some stress off your knees and hips while in the boot. I would not advise you try to bear weight without the boot until you can walk unsupported with the boot on and be guided by your doctors and therapist when you get to this stage. This will be the most risky stage of your recovery and you will find an increased awareness of every little crack in the ground. The risk subsides from 12 weeks but that depends on the type of therapy you do and how much remodelling your tendon has done.

  24. Dealt with tendoitis for years but a MRI showed a spur. Had it removed on March 7 along with a debridement. While in the splint, using crutches, on March 12 stepped up a curb and ruptured the right Achilles. Never had any pain or issues with that side, ever. Dr put me in walking boot and had ATR on 3/24. Casts on both feet was not fun. Had to crawl. Progressed to walking boots (slept with both for a month) and started PT - 3 times a week. I got really good in those boots. Transitioned out of the boots on 7/1. Continued PT and the right side responded well. Left side did not. Still swollen with large lump on back of heel and lots of pain. Another MRI shows that the left Achilles is completely ruptured. Dr feels it either happened when the right side ruptured or I developed a small tear that during PT kept growing. Achilles repair and tendon transferred scheduled for 8/25. Not looking forward to starting over.

  25. I had fhl transfer surgery in January. Progressing well but still have ankle pain and stiffness. I am having trouble finding sneakers … should they be firm or cushiony? Can’t find any recommendations. Also have soreness where shoes hit Achilles in the back… anyone have a suggestion? I have normally worn asics kayano but now find toe box too narrow. Tried hoka Clifton. They are comfortable but not sure if the cushioning is good for Achilles.
    Thanks in advance for your help

  26. Barbara, you probably dont need an answer anymore but i bought a silipos achilles heel sleeve from Amazon they work very well on your soreness at the heel. Slip one on, then a sock and you will have no discomfort from the heel rubbing on the shoe. I also purchase a pair of Hoka’s for walking. Hope this helps.

  27. I had FHL transfer due to chronic Achilles Tendonosis, Haglund Deformity, and bursitis, on November 15th. This was the first time I have really been cut on in 22yrs since I had my son it was awful. I was in pain couldn’t use the crutches fell with them on the night after surgery trying to get into the house. My daughter got me a walker and shower chair the next day. I was sent home in splint for two weeks went back get stitches out and cast but was not healed enough so got wait one more week. That nerve block was everything it helped a lot with the pain plus pain meds. Hopefully I get stitches out Monday and boot on after three weeks. I have been dealing with these left foot issues for over 3 years it was getting harder for me to walk in pain all the time 7 days week 365 days year. I’m hoping the surgery will give me relief and I can walk better once it has fully healed up.

  28. 5 yrs ago I had a total Achilles rupture. Followed every instruction by MD. My calf died. Atrophy . Did a EMG no nerve damage. Surgeon’s response I don’t know what happened. Here’s what happened you didn’t hook me up correctly! I just had a FHL tendon transfer o11/29to give me support so I don’t limp. I am so depressed 4 weeks post op in a boot. Burning and pain. I have to be in the boot for 2 months. I am praying I won’t limp after all this is done. After reading blogs I am totally worried but I will keep keeping on and hope for the best.

  29. Roxanne it is a long hard road to a full recovery my doctor said from 6 months to year. They say the burning and pain is the nerves trying to heal. It will wake me up out my sleep sometimes plus my foot be switching. I’m going into week 6 this coming week can start full weight on it in the boot. Plus I’ll begin my physical therapy 29th I’m not looking forward to that either. Even with the FHL transfer the doctor said it possible I may have a limp. I’ll take the limp as long as I’m not in pain anymore. He gave me 75% improvement I’m hoping that’s exactly what I get. Hang in there hopefully things get better.