Tendon Elongation

Hi All,

I am 10 weeks post op for tendon shortening surgery.  I have started doing calf raises and other theraband activities for strength.  I had my first full day  out of the boot at 9 weeks and 4 days but wearing a heel wedge in my shoes to avoid any dorsi flexion.  Any concerns with being out this early?

Having gone through this ordeal twice I am obsessed with anything that may cause risk of tendon elongation or rupture.  Not sure if anyone can answer this but I don’t understand what the difference is between doing calf raises and stretching the tendon with dorsi-flexion.  Isn’t putting the tendon under load with calf raises putting the same tensile stress on the tendon as stretching it?  Most protocols allow for strengthening exercises but avoiding dorsi-flexion exercises.


7 Responses to “Tendon Elongation”

  1. I can answer what I have learnt from my experience, reading studies and picking my doctor’s and PT’s brains about it. I went non-op and there is bigger danger of healing long with non-ops (I know you had that unfortunate experience with surgery), so my doctor and PT were very particular about doing everything so that I do not heal long.
    1) While in the boot my angle of plantar flexion was bigger than my protocol suggested since my leg was pretty flexible in plantar flexion. That allowed for the tendon ends to be as close to each other as possible, thus allowing for less scar tissue to form between ends. Doc also took more conservative route while I was in the boot as far as angle adjustment. I was told to keep last wedge longer, even though my protocol was calling for neutral.
    2) When I got out of the boot at week 10, I was told to keep some heel cushion in my shoe to keep my foot in plantar flexion (thus not stretching the tendon/calf prematurely). I also found out that having shoes with heel elevation plus inserts was helping since there was reduced stress on tendon. Exercises were initially done with towel or foam under my heels to avoid dorsi flexion.
    3) My stretching did not start until week 19. This is the most conservative approach from what I have read about, but this really worked for me so far. I was doing a lot of strength exercises from the beginning of PT, but all in plantar flexion. Stretching came later and I am still working on it (I am in month 5 today). Because of this approach, my calf did not overstretched, I did not heal long and the stretch is progressing well thus far and does not limit me from any strength exercises, hiking, running, yoga.

    So long story short: stretching too early (putting foot in dorsi flexion) can cause to heel long. Doing calf raises on flat surface, not stairs in early stages, has been proven to promote tendon healing. When you do calf raise your foot is in plantar flexion, so you are not stretching calf/tendon. In later stages when dorsi flexion stretching is introduced one can start doing calf raises on stairs, where your foot goes into dorsiflexion at the bottom and plantar at the top.

  2. I don’t believe there is any difference between doing calf raises and “stretching” the tendon with dorsi-flexion. The achilles basically connects the calf muscles to the heel, so both flexing the calf or pulling the foot into dorsi-flexion will have the same effect. Like pulling on either end of a rope. As you stated, in both cases, you are applying a tensile stess on the tendon.

    (Regarding the term “stretching”, I think it’s a misnomer, as my understanding is that tendons do not actually stretch. Which makes sense, because if the achilles was able to stretch then it would make explosive actions like jumping nearly impossible because the achilles would simply stretch in response to the muscle contraction.)

    The reason that the foot is held in plantar flexion early on is to minimize the tension on the achilles. This ensures that sutures aren’t pulled apart (surgical) or that the two ends stay close together (non-op) while the tendon heals. When too much tension is placed on the achilles too early, the ends pull apart and scar tissue forms in the gap resulting in elongation (or worst case re-rupture).

    If you’ve been given the go ahead to do calf raises, then you’re probably okay to also start doing some dorsi-flexion ROM exercises as well. Start slow (therabands or on flat ground) and gradually build up to stairs. Assuming you didn’t have any healing issues the first time, your tendon should be in pretty good shape by this point. But if you’re concerned, I don’t think there’d be any long term negative effects to delaying your dorsi-flexion exercises.

    Your timeline thus far is similar to mine (non-op).

    I was in shoes with wedges starting at around 9 weeks also. I’m at 11 months now, and am happy with the progress/result thus far. The achilles does feel slightly longer, and single heel raise height is slightly less (estimate less 0.5-in difference). During my own recovery, scar tissue buildup was really the limiting factor for dorsi-flexion, and it didn’t really improve until the massage therapist started working on it.

    Usual disclaimers: not a medical professional; opinions based on my own experience; YMMV.

  3. Thanks Agnesatr for clarifying “calf pulses” and your reply. My physician echoes what you are saying…logically (albeit not qualified medical professional opinion) it would seem that whether you are stretching your tendon or doing a calf raise the tendon comes under the same strain. I agree the foot is in plantar flexion….but the calf is pulling the tendon up.

    I have enjoyed reading your blog and it sounds like you are healing quite well….keep up the good work.


  4. Thanks Simon,

    I agree with your logic….in my unqualified medical opinion. Just curious why alot of the protocols allow for calf raises….but not dorsi-flexion.

    I guess my real worry is whether at 9 weeks my tendon is at risk of “pulling apart the ends” or not. The doc says if my calf feels fine….I should continue but if it hurts to back off. I have been doing 2X10 sets of double heel lifts…..and therabands. Hope I am not stretching anything here.

    Thanks again


  5. It’s been a while since I’ve looked at the protocols, but my recollection is that once you’re out of the boot, you’re usually able to start working on both dorsi- and plantar-flexion. For example: http://achillesblog.com/normofthenorth/the-non-surgical-protocol-ive-been-following/

    That being said, a possible reason to delay dorsi-flexion exercises is that it’s probably easier to overdo it. When doing calf raises, the tension on your achilles is effectively limited by the strength of your severely weakened calf. However, in dorsi-flexion exercises, you could be applying your full body weight (e.g., when standing one-legged with your heel over the edge of a step). Also, I think the calf is able to exert more force when its elongated (e.g. when dorsi-flexed), than when its partially contracted. Hence, the difficulties we have getting that last little bit of full height on the single leg heel lift.

    Since its obviously a major concern, take it easy with the exercises. Maybe take a few days off between workouts to allow any micro tears to heal. There’s no need to push too hard; you can still get good results.

    When I raised similar concerns to my doc, he just felt my achilles and said that I should be okay since it had healed nice and thick with scar tissue. One test I used to assure myself was to make sure that I could point my toes the same amount with both feet.

  6. Simon, your post is reassuring.

    I’m at 14 weeks Post Op. I can do 2 foot calf raises to about 60%. At that point my repaired leg can’t go any further. If I take the full weight onto my good leg I can get both feet to full tiptoe, but it feels as if the surgically repaired side is sort of skipping from 60% to 100%, as if it jumps in place. There is no control in that 40%, so I can’t keep it somewhere in between.

    I have been expressing concerns about an elongated tendon, by my surgeon has stated the tendon feels nice and thick and i do have a ton of scar tissue. Now I am hoping its just a lack of strength and eventually I’ll get that mechanical advantage back.

    My range of motion is almost symmetrical. There is actually a +1-2% difference in full dorsiflexion in favor of my repaired achilles. This was noticable day 1 once the boot was removed at 6 weeks. This is where my nervousness started. My PT and Surgeon attributed it to being full weight bearing from week 1 post op and allowing that very slight range in the boot that prevented a loss of motion.

    I am interested to hear your thoughts.

  7. syzygy,

    I also had something similar to what you described where my ankle would pop/jump from 60% to 100%. I think it might have been due to weakness in the calf and the tendency to over compensate with other muscles in the ankle area, especially with all the focus on being able to do single leg heel raises as early as possible.

    I started focusing on activating the calf muscles only when doing heel raises even if it was a “step back” in that i couldnt go as high and needed to help with the other leg. I found it easiest to isolate my calf by doing assisted heel raises with a chair behind me and resting my good foot on the seat (knee bent about 90deg). Also can do it with the chair in front. If you still aren’t able to work your way into that 40% of the range, then maybe more Theraband exercises.

    As for dorsiflexion range, it eventually (>6 months) got pretty good but not equal to my good leg. Around 13/14 weeks I was just starting physio.

    I’m surprised that you already have about the same range as your good leg? How does your plantar flexion compare? If they’re similar, then i think that’s a good sign. But you probably won’t know for certain until later on after you’ve had a chance to build up more strength.

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