week 3 update

Tomorrow will be the 3 week mark for me. Things seem to be going well, boot walking is getting easier. Incision is healing well and was told I could go into a pool.

I had my 4th pt appointment today. I’m a little concerned that the pt was overly aggressive with the dorsiflexion today. I mentioned that I wasn’t supposed to go past neutral and she got me to 5 degrees. It is the first time it has been stretched past neutral.

There was also a super sharp pain with burning while she was massaging my incision. Not related to stretching and everything was fine after a few minutes so I’m hoping it was scar tissue or something.

I think I’m going to find a new pt as I felt that she ignored both my comments and also my docs protocol (to not got past neutral). I’m hoping I’m nipping any potential healing long worries in the bud by switching pt…

13 Responses to “week 3 update”

  1. Well, I didn’t start pt till about week 4 and 3 days when I had the boot, but from what I know as long as the achilles tendon is healed a little aggressive stretching will not hurt I know everyone is different, but the stretching beyond neutral hurt like nobodies business, but the benefit was the next day I had better rom. At this time I can walk on my foot with one crutch, and when I have two I can imitate foot movements better thanks to more dorsiflexion movement. But you know your body best.

  2. @Mags — A nice sharp burning with no long lasting pain sounds consistent with scar tissue popping off in my experience, so I wouldn’t be too worried. But good call on finding a new PT if the current one makes you nervous. You want that relationship to be one of trust (and competence), particularly once you start getting into more aggressive rehabilitation.

    As for healing long, one thing to be potentially be wary of: when I was planning my own recovery protocol I did a lot of research on here and observed that people who incorporated early swimming self-reported healing long with a higher incidence than those who didn’t use the pool.

    I have no hard stats to back this up, and it’s possible that it could entirely be explained by something else (e.g. swimmers are more aggressive rehabbers and/or more inclined to notice and report something that feels off, etc.), but it was enough to make me think twice about it. I can’t really offer an explanation as to why, either, but If you try kicking with your non-injured leg I think you’ll see there’s a lot of pointing and flexing of the calf going on, and it’s entirely possible that the flexing occurs even while booted and gives the still-healing achilles a slight tug. I’m not sure.

    @chris89 — I think you’re right that “as long as the achilles tendon is healed” a little aggressive stretching will not hurt BUT the question is when is the tendon healed? (e.g. not stretchy to the point where you can do damage). I really don’t know if it’s all that quickly.

  3. Awaiting Moderation - Grrrr!

    Here’s another try, less of a URL :

    It is sad but true that some PTs do harm by prescribing too much, too soon. Mine gave me a painful 1-month setback after my ATR #1, as I outline on my blog.
    And the “Marfell Family Achilles Forum” link on the Main Page here used to point to a very useful ATR section (now vanished) of the Marfell Family Blog, where they surveyed a bunch of ATR folks who had reruptured and asked them what caused it, and listed the results. The most common answer was “slips” or “falls”, but the second most common was “Physio”! (Unfortunately, I can’t find a trace of that useful discussion on Archive.org, and it’s totally vanished from today’s Marfell Family website.)

  4. Chris89, if you end up healing long, your above “I know everyone is different, but the stretching beyond neutral hurt like nobodies business, but the benefit was the next day I had better rom. At this time I can walk on my foot with one crutch, and when I have two I can imitate foot movements better thanks to more dorsiflexion movement.” will be a key bit of evidence in the Root Cause analysys. OTOH, if you heal perfectly, we can make it a Sticky…
    Increased ROM (DF) can certainly indicate a longer AT. It can also come from busted adhesions.

  5. Norm, you mea doing too much dorsi is a bad thing? How else do you get it to go up beside painful stretching.

  6. Yes, Chris. Doing too much of ANYTHING during rehab is a bad thing — that’s why they call it TOO much!!

    Quite a few ATR patients, op and non-op, end up Healing (too) Long, and the simplest assumption is that it comes from over-stretching while the tendon is weak and “impressionable” — either stretching intentionally, or slipping and falling and stretching it that way. Healing long is a major cause of dissatisfaction, because it causes weakness and asymmetry. Most of the most successful rehab protocols — UWO is the one I’m most familiar with, bit.ly/UWOProtocol — wait quite a few weeks before allowing their patients to dorsiflex past neutral, and then only “actively” (using your internal leg muscles) for another few weeks.

    Pain during ATR rehab is generally a Bad Thing, with only a very few exceptions. A number of post-op patients who had nasty adhesions (adjacent layers of tissue that had grown together with scar tissue) had those broken up with painful deep massage, including Graston technique. A few others got similar relief from slips and falls that scared the @$% out of them (because they thought they’d reruptured). That’s about the only cases of “pain for gain” I can think of offhand, and all the rest is to be avoided.

  7. My OS told both me and my PT to absolutely not to stretch the tendon before week 12 just to make sure it doesn’t heal long. He also said he had never seen a patient whos tendon didn’t end up in correct length despite waiting 12 weeks with passive stretching. I followed this advice and now at week 18 I almost have full DF rom (6 weeks of stretching). At week 12 i could barely get past neutral (knee 13 cm from wall at the knee to wall test, now I’m at -10 cm with toe).

    I don’t see any point in rushing the stretching because it would only increase the risk of healing long. It WILL return to full ROM in time if you had a normal repair. If you went non op you will probably have to be even more careful.

    My OS also told me that the problem with PT’s is that they want everything to go back to normal as quickly as possible (ROM, strength etc) but few are aware of the risks with healing long.

  8. @chrislondon - that is an interesting approach. I’ve heard of the “not past neutral” until 6 to 8 weeks but not out to 12 weeks.

    It seems that if one were to go to two shoes before week 12 in that scenario, they would be actively stretching it past neutral (or walking would be almost impossible). I’m not an expert by any stretch, I’m just trying to picture walking with shoes without going past neutral.

    I do agree that PTs want to get to normal quickly, that was the vibe I got from mine which is why I’m looking to change.

  9. Mags - I concur. I don’t feel at 3 weeks you should be actively stretching the hell out of this. You should only be doing passive stretching (i.e. no external force). If this is how your PT wants to work now then how will it be later. My first PT set my boot wrong and ignored the docs orders. Found another and it was put right but there was a couple of weeks in between. I was NWB at the time and all seems to have healed fine. She was concerned about healing long and had attended a conference recently with some world leading expert talking about that very thing. Your tendon should be knitted with type III collagen by now so as long as you do not continue this all should be OK.

  10. Mags, yes you are right about stretching while walking. I think you just need a little DF to be able to walk anyway. The point is that having the PT perform stretching execises with the goal to reach max df as soon as possible is probably counter productive. Walking in 2 shoes from week 8ish probably adds just about the right amount of stretch for that period.

    And to be honest the tendon seems to stretch out by itself from just walking. This is obviously just my personal observation but I’ve read about similar experiences on this blog. I don’t really push hard on stretching but I do the knee to wall test every day just to make sure I don’t go backwards in rom.

    Also, this is about semantics but passive stretching is when you apply external force on the joint and active stretching is when you have the joint move with your own muscles connected to that joint. It’s the passive stetching that you should be really careful with. Active stretching is probably not harmful at all if done with moderation even early on. Again, this is just my own thoughts and after all im just regular Atr guy on this site. :)

  11. Thanks Chris for the correction - you are right. Not sure where my head was with that passive and active. With my current tendon injury (bicep) my doc wanted only passive so I get a bit confused. I think it is important to be correct with terms or other people can get confused as well. Cheers.

  12. Thanks for the clarification.
    I find the two terms confusing myself, which is why I’m glad my doctor told me that I could do unassisted stretching with my foot right now. Now that, I could totally understand correctly! :)

  13. Thanks for your post mags11. in two days will mark my 3rd week post op and although i’m still in a cast its good to know how much progress can be right around the corner. best of luck.

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