Crawling along

December 5th, 2012

I know I shouldn’t compare myself to others but I can’t help wondering how people are able to walk at 8 or 9 weeks post-injury. Am I missing something? I was in a cast for 10 weeks the first go around and when the cast came off I was limping and felt like a steel rod was in my leg - no flexibility. Any tips as I go into round 3? What are the signs that I am on a good road to recovery?


14 Responses to “Crawling along”

  1. californiaguy on December 5, 2012 9:01 pm

    When I first transitioned from the boot to walking, I had very limited dorsiflexion and my ankle/foot was weak from the lack of use. At most, I was able to achieve a neutral position, as far as my dorsiflexion was concerned. I began walking around my house in a shuffling fashion. I like to call it the “ATR shuffle”.

    This entailed leading with my bad food, and bringing the toes of my good foot in alignment with the heal of my bad foot. Just shuffling around the house this way allowed me to regain strength in my bad foot without having to challenge my limited dorsiflexion. Some days, I would throw on my headphones and walk back and forth down the hallway for up to an hour.

    I decided that I was OK with having limited dorsiflexion as I was more worried about healing long than I was about early mobility. As the weeks progressed after week 8, I would bring my good foot further up into my stride. Instead of bringing my good foot in alignment with the heel of my bad foot, I would bring it up to mid foot. Then, up to my toes. I did this until I was walking one foot in front of the other.

    Although I started shuffling around the house about week 8, I didn’t start actively stretching until week 12. I felt the shuffling around was enough to gradually start breaking up the stiffness and adhesion in my ankle in a slow and controlled manner.

    It was a slow incremental process, but you eventually get there.

  2. lizzie on December 5, 2012 9:54 pm

    Thank-you so much for your encouragement - this is helping me to put things in perspective. I had to lol on the “ATR shuffle”. I get it.

    I have had 2 debridements now so I am hoping my foot will be not so stiff when I get back to physio.

    I have read a bit about “healing long”, but I don’t understand what that means. Can you explain it or point me to a place where it spells it out. I guess it is another pitfall I need to figure out before I wind up under the knife for a fourth time.

  3. californiaguy on December 5, 2012 10:26 pm

    “Healing long” is referring to the length of the tendon once it is healed. Sometimes, when the gap closes between the two ends of the rutured tendon, the outcome is that the tendon is a bit longer than original. Or, sometimes, it is a bit longer than the good leg(assuming that the 2 were relatively the same length pre-injury). That’s another way to compare.

    So when there’s that little extra length in the tendon, it can contribute to a strength deficiency once healed. This seems to make sense to me from a mechanical perspective since the tendon acts as a pulley for the foot. And, a little extra length would mean that the “pulley” is not as tight as it needs to be. But, that’s just a guess on my part.

    I think the jury is still out as to what causes healing long. Some think it’s due to overaggressive stretching in PT. It could be just the way it healed. It could be overaggressive strengthening exercises before the tendon is healed enough.

    It seems pretty common that the possibility of a re-rupture begins to diminish after the 16th week. People on this blog have referred to that is the “danger zone”. If there’s a “danger zone” for healing long, I haven’t heard of it.

    This person’s blog has quite a bit of information about healing long. He had healed long and decided to go in for another surgery to have it shortened. You may want to glance over it to learn more about it. I think it’s important to be aware of it, but I don’t want to scare you here. The surgeon pulls the two ends together when they stitch it back together so it heals at the proper length. I was more concerned about it because I went the non-op route. But, both op and non-op can still have results where the tendon heals long.

    http://achillesblog.com/tomtom/

  4. kkirk on December 6, 2012 1:05 am

    Im 8 weeks and still in the boot at this point. I still progressing to FWB and my foot is too weak to even do the “ATR shuffle”. I can shuffle in my boot without help of my cane or a crutch, but only once down the hallway And back before the ankle stiffness and pain gets to unbearable. Each day I can shuffle a little bit more than the last, so Im definitely don’t see myself walking in my shoes for at least another 2-3 weeks. Best advice I can give is to trust what your body is telling you when going through your recovery and physical therapy.

  5. normofthenorth on December 6, 2012 3:17 am

    At least with fast modern protocols like bit.ly/UWOProtocol , the risks of healing long don’t seem to vary much between op and non-op. Specifically, that UWO study measured strength and ROM in their two randomized groups and mostly found them close enough to be statistically identical in ~150 patients, which is pretty close. A longer-than-normal AT would tend to affect both strength and ROM.

    Many Docs and PTs list healing long as a special risk of non-op treatment, based on logic while staring at the ceiling. Staring at the experimental data from randomized studies doesn’t give that thought much support, AFAICS.

    Logically, it seems obvious that an AT that’s repaired surgically to be the right length will be more likely to heal at the right length than one that’s immobilized and left to heal non-op — all the more so when there’s a palpable gap between the two ATR ends, as there usually is in a normal overstress ATR. But somehow, perhaps guided by an intact sheath around the torn AT, natural healing usually does about as good a job as the average OS at getting the length right, according to the evidence. (Heck, we still only partly understand how Aspirin/ASA kills pain. . .)

  6. normofthenorth on December 6, 2012 3:20 am

    BTW, being in a cast for 10 weeks then coming out and being expected to walk — sometimes even in shoes!! — is nuts, IMHO. The good modern protocols (like the bit.ly one linked right above) are way more gradual than that, with exercise and PT and PWB starting as early as 2 weeks post-either, and FWB at 4 weeks. With that prep, walking (or shuffling) in shoes at 8 weeks is much more reasonable — and safer, too.

  7. ryanb on December 6, 2012 10:41 am

    Adding to Norms comments- ~10 weeks in a cast leads to all sorts of (bad) side-effects, joint stiffness, atrophy, and weakness in all the muscles that *weren’t* damaged. So, in addition to rehabilitating an injured Achilles, you’ve got to do so on weak leg with a compromised foot and ankle joint.

    These days, when you have knee surgery, the doc usually wants you up and walking the next day. It is commonly accepted that (in almost all cases) early mobility and weight bearing is very beneficial. 30 years ago, that was not the case.

    The evidence seems to point in the same direction for Achilles injuries: early (not the next day) activity and weight bearing does a lot of good. It’s just not as universally accepted yet. I have yet to see a study that went too far: one where they found the point at which further accelerating the recovery schedule started leading to statistically worse results (Norm?). I took one of the very fastest protocols I could find, and then (I was surgical) went a bit faster than that. I was walking in two shoes at 5.5 weeks.

  8. normofthenorth on December 6, 2012 1:41 pm

    No, Ryan, I haven’t seen a study that explored the territory of “too fast” either. The “studies and protocols” link on the main page here takes you to a number of studies of “early WB” etc, and the fastest ones seem to produce results as good or better than the slower ones. My general impression is that going slow post-op is more a dumb inconvenience than a clinical problem. But going slow post-non-op actually produces worse results in addition to the dumb inconvenience. Unfortunately “logic” — the same kind that determines just HOW many angels is TOO many for the head of one pin — dictates that non-op recovery should take more time than post-op, so there’s still a lot of malpractice afoot.

    But I’d be nervous about going significantly faster than the fastest protocols in modern studies — like bit.ly/UWOProtocol — because there’s no evidence to support that either, just “logical” inference from a lack of evidence. And a few anecdotes, including some here.

  9. ryanb on December 6, 2012 3:41 pm

    I’m sure there is a limit, a pace beyond which results start to get worse. I just don’t know where it is. Protocols like UWO, have shown that accelerating the recovery schedule (much faster than the “old school”, prolonged NWB/casted) yields both better and safer results. Is that the fastest you can go? I don’t know. I took a bit of a gamble - figuring that I had a few factors working in my favor (relatively young, pretty fit, very short period between injury and surgery, doing what I could with nutrition etc.) - so I hypothesized that there was probably a little statistical margin in the published protocols that I could take advantage of. Maybe I was right, maybe I was just lucky. Maybe, in time, we’ll learn that going faster than UWO is even better (or not).

    The only way to determine the result (statistically significant - anecdotal point cases such as myself don’t count for much, other than to affirm that it doesn’t always fail) of an even faster protocol - is for somebody to do a real study which goes too fast. We’ll only find that line by crossing it. It will be unfortunate for the folks on the wrong side of those studies. Some might argue: what’s the point of going faster than UWO?? Well, I imagine not that long ago, somebody argued: what’s the point of trying to be NWB for less than a week after knee surgery? Turns out, there are real benefits.

    Until those studies happen - I’m actually in violent agreement with Norm. Most should play the odds and stick with the protocols that have shown the best statistical results - something akin to UWO. Since, so far, it seems that faster == better, I sure would like to see the medical community strive to determine just how far that axiom holds. At some pace, I would expect the surgical and non surgical cases to diverge. The fact that op and non-op cases have almost identical results with UWO actually suggests - to me - that the surgical folks may be able to go faster yet. Common sense (which as Norm points out, is often wrong here) tells me that the surgical folks should benefit from a bit of a head start… they don’t need to wait for the tendon ends to “find” eachother.

  10. lizzie on December 6, 2012 9:11 pm

    Thank-you for all the replies — really helpful. I have to agree that being in a cast for 10 weeks (it was actually 12 because I had to wait for surgery) meant my foot was a limp noodle when I went into 2 shoes. When I ruptured a second time, in less than a week without a cast, the surgeon changed the protocol because it was more harmful to be in a cast for another 10 weeks. I got to move to a boot 6 weeks post surgery.

    I am back in a splint for at least two weeks, post third surgery. I might go back into the boot on Monday or be recast.

    Do you have any advice, comments, thoughts about how to rebuild back my foot and leg safely after this long a period of immobilization? (I have been in a cast since July 7th).

  11. lizzie on December 7, 2012 11:12 am

    Also thank-you Normofthenorth for the information about the UWO protocol. I think that whenever I am back in two shoes I will use crutches until my leg is strong enough to be safe from re-rupture.

  12. ryanb on December 7, 2012 5:12 pm

    Lizzie- unfortunately, I don’t have any specific advice to offer for somebody with such a long period of immobilization. Generally, my advice is to try and make slow, but steady, progress - as incrementally as possible. I think that advice is good, regardless of how deep of a recovery hole you’ve got to climb out of. Work on always stretching your capability- but never make too big of a step (be it a new activity, duration, resistance level, etc.) all at once. Try to make one new, small incremental, step almost every day though. Remember that the consequences of doing something new might take a couple of days to appear ;-)

    PS: Sorry for sort of hijacking this thread earlier-

  13. lizzie on December 7, 2012 6:55 pm

    No apology needed. It is all really interesting and helpful. Thanks! Slow and steady will be my new mantra.

  14. Muriel on December 10, 2012 7:15 am

    Hi Lizzie,
    I would like to echo Ryan’s comments. You’ve had a long period of forced immobilisation and all sorts of muscles will have atrophied, they need to be woken up gently and gradually. I was only in a cast for 4 weeks (then cam boot) and that was long enough, and I was horrified by how quickly my leg muscles had melted away - the calf muscle of course, but also the front of the lower leg, around the ankle and under the foot. I am now 15 weeks and the finer muscles that control the balance when walking are just waking up again now that I am wearing shoes indoors. Things that did help me in the early days were:
    a) massaging/pinching my toes - this helped wake up the nerves and get the blood going again;
    b) massaging the calf muscle and around the ankle = gently at first then a bit more vigorously as I gained confidence;
    c) massaging behind the knee, there is a point that stimulates the lymphatic system and helps reduce swelling; cold shower bursts on the foot also helped
    d) vitamin E cream from toe to knee, as my skin was very dry after being in the cast;
    e) accepting that this is not a race and it will take the time it takes.

    Like you I read on this forum that some people can run & jog at 14 weeks. That’s great for them but I know I am not at this point. I also reasoned that being a couple of weeks slower is nothing compared to re-rupturing. My surgeon said that his best patient in terms of speed of recovering was 65+ y.o. not particularly fit, while he treats hockey athletes in their 20s who take longer to recover. There is no “normal” speed of recovery, it’s more of a broad range!

    Maybe you can get a physio referral early - I saw mine at 5 weeks, 30 min a week so not loads of time with him but he has been very good at giving me “bite size targets”, things i can aim for in a 2 week period, with gentle exercises that build up over time. Psychologically this really helped as I could see I was progressing, at a pace that was right for me.

    Good luck.

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    ATR Timeline
    • Name: lizzie
      Location: Toronto
      Injured during: skipping rope
      Which Leg: L
      Status: 2-Shoes

      445 wks  1 day Post-ATR
      438 wks  2 days
         Since start of treatment