Pain and lack of Progress
My dog’s face says it all. The doc called yesterday and told me that if I don’t move forward with ROM that I’ll need a surgery to release my tendon in the future - HELP! I have very little ROM at 6 weeks - I’m still at 5 degrees and stretching doesn’t work - the AT is like a board. Sooo…in great terror of the above, I cranked the Vaco down to zero yesterday and have been in misery for 24 hours. (Think Jodi’s last post) Has anyone else struggled with ROM at 6 weeks? The PT stretches it brutally every time I go (3x per week), and I made gains for the first 2 weeks - then came to a standstill. I actually lost ROM when I started PWB last week. sigh.
I don’t do any theraband stuff - does that help? The PT said it was too early. I switched to my other boot in the afternoon - but couldn’t get the heel down to zero. Apparently, the big foam build up in the heel of my Vaco liner has me somewhere above 0 degrees - which is still painful - so won’t be able to use the other boot for relief of hotspots until I get more flex.
Please post any success stories with limited ROM at first. What is the window for stretching the AT and calf to zero and beyond? Am I past it at 6 weeks?? The doc is scaring the tar out of me! Thanks, Kim
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My swelling never went down until about 10 mos. postop - and in the last couple of months I’ve been able to fit in old shoes, etc. My ankle bones no longer have a “sea of swelling around them” and everything looks pretty normal. 
)
And to avoid confusion - I can’t get to “flat” 90 in the boot. I’m 5 degrees from that.
Hi Kim,
I don’t know how well this would fit your situation, but here is what I did starting 2 1/2 weeks postop. I took off my splint, (I never had a boot), got into two shoes, and starting walking around, (very carefully!), keeping my injured foot way out in front. As the next week went by, I was able to bring my good foot forward more as I walked. It worked for me, (more details at my blog page). It is an approach that may have its dangers, but if the alternative really is surgery, you may not have much to lose.
Best wishes,
Doug
Kim, FWIW, I did not work on dorsiflexion (toes up) ROM very hard until around 12 weeks. My therapist tried to get me to push it harder/sooner- but I decided to wait, I was concerned about a re-rupture, and (more) about over-stretching the healing tendon, causing a “healing long” result. I limited myself to active stretching for quite a while.
I was not worried about healing too short. I figured that the muscle could always be stretched to regain range of motion. To be honest, I was sort of hoping for a healing (slightly) short result. I still have some limitation; but with a lot of work, I now have almost full range of motion. Long term, waiting until 12 weeks didn’t do me any harm. That said, Norm has recently discovered that he is “short”- and it’s causing him some problems… but I’ll let him provide more details.
There are lots of things that can limit ROM. The tendon can be too short. The muscle can be too short. The joint itself (ligaments and such) can be damaged - I think many ATR’s have a coincident severe ankle sprain, as the normal ROM is grossly exceeded when the AT breaks. Swelling in the joint can limit ROM. You can have scar tissue and adhesions. Keeping the ankle as mobile as possible, during the early phases can help with a lot of that- reducing swelling, preventing scar tissue and adhesions, etc. At 6 weeks though, you sort of “are where you are” regarding a lot of that.
Unfortunately, if you have limited ROM, it can be hard to determine the exact cause. Some are probably more important to address early than others-
Reading back over that; I realize it’s probably not helpful at all
I was DF ROM-limited after my first ATR was repaired surgically, and I still am. When I asked my OS about it, he said “Good, that’s what I was aiming for, to make sure you don’t heal long.” My latest blog page suggests that healing short can also cause some problems, and what they might be.
What does your surgeon say about how much tendon he trimmed off?
People do have surgery to lengthen short ATs. My FiL had it done in childhood because he always walked on his toes. Basically they give you an artificial ATR then let it heal “non-op”, but without the usual DF angle during immobilization (or without as much DF). The body reattaches the ends, constructing new tendon in-between. FiL never had any problems after the casts came off.
But I’m with Doug. If the alternative really is surgery, it’s presumably worth stretching hard, like on the floor using some of your weight.
OTOH (sorry, too many hands!), if your ROM is limited by swelling or anything else other than AT length, you may be responding to false readings. It’s important to get to the truth about the problem, before getting too aggressive with a solution!
Traditionally, I’ve been a wimp about DF and stretching, a la RyanB. I still think more ATR patients suffer fromhealing long than short, though a surgeon can easily shorten the ends…
You really shouldn’t fret over this, Kim. Not in my opinion anyway. At six weeks you should still be focused on active movements like Ryan was saying. Many surgeons (mine included) won’t even allow passive DF until after six weeks, at which point it is very gentle. I’ve found, the more I walk, the more it loosens up so keep that in mind. I’m at week 12 now, only been WBAT since right around week 7. At week 7, I was at 2 degrees of DF actively. At week 10, I was at 6 degrees. Haven’t been to PT since that last measure but likely I’m 2 degrees or so better at 12 weeks. Get to walkin’ and gentle stretching when you’re allowed. No worries.
-GK
The little beads in my Vaco boot built up in the heel too, filling that mostly came from above the ankle. This had the add-on effect of causing less protection and support further up.
In my case, solved this quickly by using the vacuum pump regularly after first evening-out the filling while it is soft and pliable (i.e. with air in it).
Apologies if I’m suggesting something that you’ve tried.
Thanks to all for the advice. My doc had to take out a lot of damaged tissue and pull what was left together. He said it would be tight and a long recovery.
Did you all just pull through the tightness? It’s worrisome to pull against seemingly rigid tissue. I can get it to zero - but it’s uncomfortably tight. Should I just grit my teeth and do it? Am I being a wimp? (doc thinks so…)
I’m glad to hear that there is a loosening with walking. I’ve been pretty swollen with initial WB after very little swelling while immobile.
It’s interesting to consider an adhesion issue - the scar feels like it’s “giving” when I pull rather than the tendon. This is such a mind game. I’m going to go through all suggestions above!
Ryanb - did you get a lot of progress after 12 weeks, or did you start pretty flat?
gk - thanks for the numbers - doesn’t sound like I’m that far behind. The doc wants me to stand barefooted and squat down slowly. I can’t even stand straight up yet!
I’ve got pictures at 8 weeks:
achillesblog.com/ryanb/2011/10/19/8-weeks-status-report/
But not at 12.
I was past flat at 8 weeks. My benchmark was: how far from the wall could I put my toes, and then touch the wall with my knee, without lifting my heel. I could measure that myself, without PT assistance. This was an exercise to *measure* ROM; not necessarily to increase it. As I said, to work on ROM, in these early days, I was limiting myself to active stretching.
As you can see in that picture, at 8 weeks, I could put my (right) toes only about an inch from the wall-
Hi Kimjax, This recovery takes a lot of dedication. As you can see by Ryans response to you. I read it myself and at that time of his post I was only about 14 days post op. I am at 8 months and STILL improving. Even though you go to PT 3X a week you have to step it up and do more at home also. I didn’t think I would ever do a squat. Or do those wall stetches like Ryan mentions getting toes to the wall. I did wall stretches 8 X’s a day for 10 minutes at a time. Plus all other excersises. It takes time to be fit. If it hurts never let the hurt hold you back. It does get better and those micro gains DO add up. I do a series of stretches still before I get out of bed. Good Luck and hang in there. Time heals all wounds! And this is a lengthly recovery.
Hey doryt, I’m working hard at home - and feel better after my PT - except for stretching. I just don’t know what is ok - and what is dangerous tension on the AT. I can see by most of the above comments that I’m probably being too conservative! I try to explain to hubby that it’s not like pushing muscles (or even stretching them) but it feels like trying to stretch a board. It just won’t stretch more than a couple of inches before becoming taut and immovable by voluntary movement. It seems that most folks are using forced movement like Ryanb. I can’t bend my knee at all when standing on it. I tried sliding my foot back towards the chair while sitting and that seems to be helping. Im going to do this as often as you are as the 2 a days don’t seem to be cutting it. PT told me to put my foot in front of the crutch handle and pull it towards me. thanks for the motivation!
Kim- I want to be sure you don’t interpret my comments/pictures the wrong way. When I said I was doing active stretching, I meant that I *WASN’T* using forced movements. I was simply using the muscles in my leg (active stretching) to pull my toes back as far as I could. That picture of me with my knee against the wall was taken just to demonstrate my range of motion. I would occasionally do that to *measure* my range of motion. But, to improve my ROM, I did very very little of that sort of thing (that’s called passive stretching).
You did ask about therabands. I did use them (well, cheap exercise rubber band devices) early, but would not describe what I did as stretching. I’d loop the rubber band over my toes, and move my ankle through it’s range of motion - with light resistance - but I’d do a ton (sometimes hundreds) of reps, while my foot was propped up watching TV.
My PT would urge me to wrap a towel around my toes and stretch them backwards… I’d go through the motions to make them happy; but until later (really, until almost 12 weeks) I was very hesitant to put any real stretch on it.
Ryanb and doryt - I’ve been a wimp! I’m doing careful stretches - but more of them -as per my PT and the above comments. I got my foot in the true zero degree boot tonight, and while it’s uncomfortable, it’s only a small stretch and nothing to worry about. I have not been consistent with stretching as evidenced by my idiotic reply to doryt. I needed a little “dressing down” about being such a wimp - I’ve been TOO worried about everything. I need to work harder at this - albeit carefully. Thanks for the motivation - you all and Oswald Chambers on his June 13 entry. (I’m behind
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Kimjax:
I totally agree with gkaemer12 - Don’t worry so much.
First the method itself is very inaccurate. The first time I was measured by therapist A, my DF was -5 degrees. A 1-1/2 weeks later, therapist B measured it at +17 degrees. A few weeks after that, therapist A measured it at +7 degrees and a few weeks ago, therapist A measured it at +12 degrees.
Second, what is “normal” is controversial. I’ve seen references that say if you can’t do 20- 30 degrees, you’ll be worthless as a sprinter. I’ve seen other sources that say you need 12-17 to walk without a limp. My therapist said it is not uncommon for construction workers to have as little as 5 because of the boots they wear.
Third, it can vary depending on time of day and recent activity. I suspect it will be stiffer in the morning than later in the day after you did some ROM with it.
Last, you got to be brave. The first time they measured my DF I was sweating out of fear. It’s not easy the first few times you pull back as hard as you can with the image of a possible re-rupture in the back of your mind.
Kim, I didn’t begin using therabands until 7 weeks and it took a good week before I could really stretch them because my ankle was so weak. My tendon feels just like you say, very rigid. After walking around in the boot it does loosen up quite a bit and I am able to go into two shoes. My shoes have two wedges in them still and I am at 12 1/2 weeks. I guess my point is I wouldn’t worry about how tight it still feels at 6 weeks. It will loosen up in time. Just keep doing your exercises and hang in there! BTW, my anti spam word was “patience”.
Thanks, Jennifer -that’s reassuring. I wonder when the rigidness begins to go away?
Congrats on 2 shoes!! Can’t wait to get there. I rode about 5 minutes barefoot on the stationary bike today and that was huge. My foot just flopped around last week, so I’m getting more control! Small milestones are so uplifting.
Hi Kim,
I also do many hamstring stretches and foam roll daily. Between the PT I do on my own now for my AT, and being back at my XFit classes it has been very difficult to balance my time I spend on the strengthening of my AT. My right leg always wants to take over and it takes a lot of mental forethought that I must focus on to get my left AT (the injured one) to overcome. My surgeon told me at 16 weeks to do whatever I wanted that my AT was not going to rerupture. So with that and trusting myself I began stepping up my activities. I am still shy of box jumps and will be for quite some time! So being conservative is not a bad thing some days my body just won’t allow some movements at XFit and I modify. Our brain is a protective tool and is our guiding strength during this recovery.
Just don’t force the movements and you should be fine. When I first began doing (and still do) the wall stretches I never force my knee to the wall. I stand relaxed and just lean into it. Even at 8 months I am still really tight. Some days I just want my husband to get the come-along from the garage and ratchet my toes to my nose for a good stretch. LOL.
I realistically think I will be looking at 18 months for a full recovery. I feel OK strength-wise even though I am weaker on the injured side. I need so much more of the strethcing so I feel fluid on every motion. Still endureing it and enjoy the gains everyday.