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
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.
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.
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 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.
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).
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 hee
I am down to 2 wedges now and will take another one out on Wednesday (7 weeks). I believe you used a vaco-cast that was set at 30 degrees..not sure what a wedge equates to.
Last week I started with FWB and so far I feel fine. I am not sure I am at a point where I can say my achilles tendon is tighter than before….this may not be known until trying to load the tendon with resistance. I find myself trying to determine if there is any delay in plantar flexion from when I tighten my calf! I know this is likely a poor test devoid of any scientific evidence..but as you know going through this twice sucks.
My incision is almost completely healed so I appear to have passed the higher risk periods of DVT, PE and incision healing issues. My ortho told me that the risk of wound healing is higher the second time. These are small steps on this long journey…but I will take the wins where I can.
For now I will continue my slow journey to plantigrade. I am diligent on the inversion, eversion and plantar flexion movements. I am also trying to really contracting my calf when I do plantar flexion….the ortho told me
My next ortho visit is at 9 weeks and the surgeon alluded that I would start PT at that time. I start PT at 12 weeks the first time…..but my protocol was almost entirely focused on DF ROM!! He practises at a reputable sports med clinic…but his approach seems contrary to the protocols (including yours) of several on this blog. I still wonder if that is where things went wrong. Nonetheless…..I am so focused on getting back to normal that I am not even at neutral yet. I will take out another wedge on Wednesday and then try to get a bit closer to neutral then.
I have also been doing some hip, core and back strengthening that I learned from the first go around. I forgot how much my hip and back felt mis-aligned from walking in the boot. I do have the even-up and this helps….
Kevin - I hope this post finds you well. Have been thinking of your progress. Those early weeks can be challenging, especially the second time round I found. But can say now that glad I had the shortening surgery as I am now stronger than pre-surgery in some ways but no where near 100%.
My protocol seconds Agnes’ comments re no aggressive dorsi stretching. My surgeon says collagen is solid after 9 months. Hope your p tendon is improving.
Transitioning to 2-shoes. I was sooooo looking forward to ditching the boot at approx 10 wks. But I needed a cane or crutch for wks 10-12 to deal with the discomfort and AT learning how to work again. Now I walk fine with slight limp during warm up phase. I started 2-shoes with 5 mm heel fits in athletic shoes and will continue so for another month or so.
My protocol was calling for range of motion in plantar flexion at 2 weeks as well. Just simple movements for 5 minutes every hr or so: https://www.youtube.com/watch?v=_RM77LGBpxA
I went non-op, but non-ops are more prone to healing long than ops. Thus far I healed well. My physio therapist has been excellent in making sure I am not doing any stretching into dorsi flexion for weeks though. We have been working on my calf/ankle/hips muscles pretty aggressively, but everything in plantar flexion I am at 18 weeks today and my PT still recommends no specific stretching into dorsi flexion. I am able to do single calf raises and running on tip toes. I feel that these early range of motion exercises helped my ankle and my walking in the shoes and let me progress well with calf pt. I understand your worry about healing long, as you did once after surgery, but from my experience the early range of motion in plantar flexion has been very beneficial. I feel that avoiding stretching for as long as possible is essential in not healing long. When are you starting your PT?
I recall reading on this site that the first 20 weeks seem to be the highest risk for re-rupture.
At 17 weeks non-op, I was able to walk around reasonably well, but still had reduced ROM and tightness in my ankle area. But, I probably could have done the activities you’re describing. That being said, I would be scared/ cautious going on sand, since uneven/unstable walking surfaces seems risky. I’d also be extra careful on any wet surfaces (e.g., pool decks).
December is still pretty far away to estimate how your recovery will have progressed by then. If you’re booking the trip now, you’re not giving yourself much of a buffer. If it’s already booked, then see how you feel closer to the date.
Thanks for comment on my blog.
I have commented on your notes in my blog.
There is also an ATR Facebook group that you can join and ask questions. There are a few folks on FB that have had shortening surgery but shortening surgeries vary from doc to doc and patient to patient.
I see now that you are in Calgary. I am in Fredericton and my surgery was in Halifax (4 hr drive).
Kevin - the anti spam word was optimism. I think you will need some and am very sorry for how things are going but at least you have a reason. Seems like this new doc is good. In the end they may say a tendon transfer but lets hope you can do this without. Could you discuss radial shock wave therapy with your doc? No silver bullet there either but it worked on my tendonitis. A lot of docs will say it is useless and a waste of money but it is newish so they may be sceptical.
I have been going up on the good leg and then shifting weight to the bad one and doing the negative. I have tried to slow the eccentric phase down but my calf is so weak that I originally couldn’t! I have only been doing them on the floor so stay neutral at this point. I have started to ramp up activities again after taking a few days off….and I feel I can slow the decline better than before now. I am going to stay at this level for the week and slowly increase the volume.
When this flared up I might have started too much too soon as I started to hit the heavy gears on the bike, incline treadmill and lunges….lesson learned.
I’ll write back more after gauging this new level of activity.
Hey Kevin, I’m so sorry to hear that you’re having problems and getting pain in the tendon. The eccentrics are supposed to cure tendonitis not cause it so it’s not good to hear that they’re making things worse for you!
When you do the eccentrics how quickly are you lowering down from tip-toes to either the floor or below a step? When I do them I take 2-3 seconds so it’s very slow (and very boring). Also how do you get up to tip-toes? Are you using your calf strength or are you using a step so that you use quads or a table so that you support your body weight as you go up? I mention all these things because I have read that there are 3 things to watch out for on the eccentrics … 1) if you have pain where the tendon joins the heel then don’t lower your heels on a step only go to the floor, 2) if you go quickly down then this can put too much tension on the tendon tissue and break it down instead of make it stronger, and 3) using the calf to raise to tip-toes (concentric) can also put strain on the tendon and should be avoided unless it’s healthy.
I hope that you come right and get back to running soon! All the best!
Yes - I have stopped the heel drops about 7 days ago and have rested. Today I did a relatively low intensity spin bike, and then walked backwards on the treadmill and my ankle has swelled up with a lump on the tendon above the heel.
Last week I would put the pain at a 7-8. It definitely is not panfry when walking.
I have another physio tomorrow…..I will bring it up.
Not a doctor, but I don’t think you should be doing the eccentric heel drops if they hurt you. Try working other leg muscles doing leg press, curls, squats, thigh abdduction, adduction, etc. Go back to the heel drops when your pain subsides. There are so many other exercises you can do to help you gain your leg strength back.
I am at the 9 week post-op mark. It takes me a few minutes to stretch and limber up in the morning. I still can’t go down stairs. Up is no problem.
Generally speaking the tendon is still pretty stiff at this point but gets better with every day. I’ve not started official PT yet, as my surgeon thought my calf was not strong enough at my 6 week appointment.
So I’ve been doing heel lifts in the pool as tolerated and been walking on my toes in addition to regular theraband exercises. The pool has helped immensely with tightness, general ROM, and swelling especially. I also am up to biking (stationary) 35 minutes a day now.
If you retain the ability to plantarflex, I surmise you’re still OK. Just listen to what your leg’s telling you and don’t push it too hard, especially with weight.
Don’t worry. I think you are doing all right. Stretching and walking is the best exercise you can do right now. I am opposite. I walk better earlier in the day. By the end of the day I am limping specially after a weekend of walking around the house and exercising at the gym. And I know my limits. I am not going to try to force anything when I am limping. As far as running at 13 weeks I don’t know if I said something that might imply I am doing some crazy stuff. I like to push myself and have been doing some light jogging/walking on the treadmill since. Very slow pace. And also strength training. But I don’t recommend it to anyone to follow my steps. I would say you should be challenged. But listen to your body and do it within your own limits. You know your body better than anyone else.
Kevin - I know of some who have re-ruptured at 19 weeks or later. The problem is you need to remodel the collagen and that only comes by loading it. Like Beanie said, take it in increments. Most re-ruptures occur with a slip or such and a few others by people doing silly things too soon. My advice is to walk a lot on good paved areas and as you get better include some hills then move onto uneven surfaces when confident. Eccentric exercises will help but you may have to go up on the good leg then go down on both slowly. As you get stronger you can transfer more weight onto the bad leg as you go down. Personally I feel there is no hurry to start running again and I doubt running at 13 weeks does your recovery any favours compared to proper strength training. Some people need that mental push though or have a need to prove something to themselves or others. I prefer to think of the end game.
Hey Kevin, I have really struggled with my ROM and dorsiflexion too and yes I also had the 15min “warm up” requirement in the morning to get flexible again. I did slowly keep getting gains each week. My advice is to regularly do exercises that stretch or work the area in some way, it worked well for me. Read my 12 and 13 week posts - it really helped me when I started doing lots of bits of stretching etc often during the day. Don’t be disheartened when you have stuck days, this happens. I’d often have an excellent day with good stretch followed by a few “sticky” days where I couldn’t stretch as far. So just keep working at it and don’t worry too much, flexibility will slowly return. Your tendon is now in the stage of hardening (since 10 weeks). It will continue to do this for about a year. if you are sensible and incremental to add movements now you should be safe. Mine took until about 19 weeks before I felt confident to push it, but everyone is individual in this, some people are jogging at 13 weeks, so I think it’s a personal process. Good luck! I’m glad to hear you’re going so well so far!
Kevin, as to dancing, I am ready for easy moves, but am being very careful because of the risk of hurting myself doing a twist or move that could cause a fall or - worse yet - a rerupture.
The fact is that I am relearning how to walk, since I don’t have the strength in my tendon to use the foot as I did before. No longer can I step down with my toes first… at least not for a good while. And I can’t turn my torso while walking, because my balance is still a work in progress.
My take on the high rerupture risk the first four months is that we make mistakes and do something that requires a fully repaired tendon, or we fall and put excessive pressure/tension on the tendon.
But if we do not walk on the foot, then the rerupture risk actually goes up, because walking is what turns our scar tissue tendon into a real live tissue tendon… which takes about a year.
Now, please focus on healing, on doing safe exercises and getting to 2-shoes as soon as possible.That’s the prize we are chasing!
I hope this helps!
Kevin - sounds pretty normal for those who have been locked up in a cast for a long time. The good news is you the difference between those who were in shoes earlier than you will diminish. The bad news is you still need to be careful as your re-rupture risk may be a bit longer. I am sure you are aware of that now anyway. Everything you are going through sounds about right so no need to worry. Keep going on strong.
Yeah Kevin, getting the feet to the same height is very important, otherwise you’re always dipping down or on tip-toes. That may be why your good achilles is a bit sore now. The EvenUp you see in the video is available online in most countries. It’s usually pretty inexpensive and arrives 1-2 days after order. It’s really great because you can strap it on to any shoe. Before I found out about EvenUp, I duct-taped an old flip-flop to the bottom of an old trainer. Not an elegant solution but it did the job
Meant to respond in my earlier post but kids got in the way! I saw the video links and I have to say you are walking much smoother than me. I am still in an aircast moon boot but I am not walking as smooth as you. I think I need to get the piece that goes on my good foot to reduce the strain on the other half of my body caused by over compensation. I am not sure if you ski or not but this experience I have is like walking with a ski boot on one leg…,,
The vacocast sounds great….but I am hopefully in this air cast for a few more weeks so I will try and just tough it out with this.
Just trying to catch up on a week’s worth of posts here! Thanks everyone Holly, Metonia, Manny and Beanie for the insight. Its all helps.
Things have gotten a lot better walking with the boot. I am pushing myself more and more with rolling my foot from heel to forefoot. I am still pretty conservative on trying to push off with my toe so trying almost roll the leg through.
I just want to add the importance of working out the rest of your muscles, especially your core. I’m not a huge exercise fanatic and am overweight but this has made me really focus on weight training and working on my core. This helps so much with the uneven walking and I have had no knee and hip pain this second time around. The first time, I was much less active and my knee and hip took a lot more of a beating.
Kevin, let me give you my 5 cents worth on “safe walking” since I first used the rolling using my calf and knee as the major movers, and now when waking quickly I do use my toes a bit. My boot actually bothers the top front of my calf when I walk a lot, so flexing the foot a little within the boot reduces that top edge’s rub on my shin bone. But that is comfort, not safety.
As I understand it, the boot keeps your foot in position so the tendon and muscle CANNOT move the foot much. so “pushing with your toes” really isn’t as long as you have your ankle held tightly within the boot.
BUT the boot is solid, clunky and if you step on a stone or an edge , you could lose your balance and fall. I caught my boot once going up stairs, and it caught on the edge of the step and I was unbalanced and fell forwards. That was also when I was going up stairs with crutches… not safe at all. And going down steps, you need to verify that you are actually well placed on the step. Right now I joyfully clunk my way down the stairs letting the boot hit the step solidly and not getting the end of the heel hung up on the step I’m trying to get
Kevin, I’m very glad the game went well and that you had fun! My philosophy is that since life is going to laugh at you anyway, you might as well have fun doing whatever you do!
As for the fear factor with the twinges, been there, done that, and looked into adult diapers! LOL
Scout motto: “Be Prepared” LOL
My surgery is today but I tried practicing in my boot the other day just to see. I am “double jointed” and found those first steps difficult because my foot wanted to roll “backwards” to rest on my heel. It took a few tries to realize I had to start off with a slight knee bend and keep it to keep my center of gravity from slightly forward, otherwise my knee kept wanting to buckle backwards.
I think I was a bit of a scaredy cat because for the first 12 weeks I refused to push with my toes or ball of my foot at all. Since this is what caused my injury, I was in no hurry to repeat. I don’t think you have to be that afraid of pushing off with your toes, others do it with no re-rupture .. but I didn’t want to.
So, instead of pushing, I used momentum and glutes to roll me forward in the boot and in 2 shoes. This gave me a full heel to toe roll with no pushing.
I found it much easier to walk in the vacocast than the hospital moon boot because of the wedge sole that lets your foot rock forward with almost no effort.
ryanb and ejbvmi have boot walking demos in their blogs, so look them up. I recorded two quick videos of my boot walking - one with the vacocast and one with the moon boot. You will notice in both that my knee bends at the end of the step, but it is more pronounced with the moon boot. In the moon boot, you really need to bend your knee and drive your shin forward into the boot so that it rolls your heel upward for you. In either boot, your knee
i had both the moon boot and now the Vacocast. In both, I was told to roll through the foot and push off with the bottom of the top of my foot. I hope that’s okay? I’d love to hear what others say as I haven’t heard of the “safe walk”.
Thanks Manny and Bryanb - volleyball went well ….made it the tournament finals but lost in a tight match that went to the last set. Good game.
FWB is coming along but man am I ever slow in this boot. I am ok with pushing through pain and fatigue…it actually makes me feel like I am beating this stupid injury…but sometimes I get a “tweak” in the tendon which scares the crap out of me.
Congratulations on coaching your son’s team, Bryan! and don’t feel bad about getting tired and having the pain overwhelm you: my doctor told me that pain was part of the process, specially when I used my foot!
I get sore all over when I go out walking, and today it was by back muscles seizing up as I waited for a bus. My leg muscles have taken three weeks to kind of recover, and other areas of the body take their turn to complain! LOL
But I’m hoping to be in shoes in 2 1/2 weeks, so I am using my legs as much as possible now, and trying to stop using a cane, too.
Thanks for the update Kevin.
So glad to hear you are making progress and were crutch free for most of the game. The real question is: Did your son’s team win the volleyball tourney..??!!?? I hope so.
I think you having muscle soreness and fatigue is a great thing. Means you’re pushing yourself to get back to normal. At least that’s what I tell myself…!!
All is good here. I go to see the doc in about ten days and we’ll see where we go from there.
In the meantime, keep up the great recover, my friend..!!!
FWB is getting there. I was coaching my son’s volleyball team at a tournament yesterday. I was crutch free and on my feet for most of the day but succumbed to pain/fatigue by the late afternoon and had to get crutches back.
I may have done too much too fast but I think its coming along although I am sore today! The soreness is not in the tendon itself but rather the general ankle and calf….so I will assume that is just due to muscle loss and movement,
Kevin, in my case it is my uninjured foot’s knee that sometimes complains, but I am wearing lifts inside that shoe to bring me up to the same height as in my moon boot. My lower back is still an issue, too. But congrats of getting rid of the wedges!