Oct 21 2008

20 Week Post Op Doc Appt.- To Cast or Not To Cast? That is the question…..

Published by marianne at 4:18 pm under Uncategorized

What to do?  I went to my 20 week post-op doc appt. today, and for those of you who have kept up with my story from the beginning, you’ll remember I’m the Wimp…..unfortunately being a wimp doesn’t go with ATR rupture recovery protocal because I have been unable to move forward for the past 6 weeks in Physical Therapy…..i’ve completed a total of 12 weeks PT and still am not at 90 degrees.  It’s not that I haven’t done all the exercises they’ve asked of me– stretching, bicycling, stepper, rocker board, squat machine, ultrasound, “massage”(ugh)—and all the at-home exercises I’ve done diligently twice a day.  I think the problem started back at about 6 weeks, when I was told to weight-bear and couldn’t stand the pain and babied my ankle because of fear and pain….I was so afraid of re-rerupture that I became stuck and on top of that wound up in the hospital with opiate withdrawl issues as I wasn’t instructed correctly about slowly stopping the meds.

So, here I am now, walking with an extreme limp and a cane, still have pain, and not at 90 degrees.  I knew the news from the doc wasn’t going to be positive when he actually took the time to sit down to talk to me  (unfortuneately, my husband had to work today and couldn’t come and help me ask pertinent questions, so I was on my own).  The doc explained to me about the option of “serial casting” telling me that it wasn’t the type of “cereal” you eat.  I told him, I figured that it wasn’t …..  He is recommending that I go back into a cast for 6 weeks again and come back every week for them to change the position of my foot to eventually get it to 90 degrees (it’s at 80 degrees and ideally should be past 90 by now), and after 6 weeks, I would wear a night brace. 

I just can’t see myself going back to a cast for 6 weeks after all the hard work I have done to get this far.  I keep thinking about the withered calf, the discomfort , the claustrophobia, of the cast experience.  He said that I have “plateaued out” with the physical therapy, and will not recommend anymore.  So, no more physio and I am wondering if I can do this on my own….Doc doesn’t know and has explained that if I don’t choose “serial casting” now and come back to him in a year and tell him my ankle isn’t good enough, it would be to late to serial cast then and he would have to go in and add more tendon to lengthen it…..Now I know I don’t want another operation :(

He has given me a week to think about what to do– cast or no cast.  I plan on talking to my Physical Therapists sometime this week to get their opinion…..I guess there is nothing easy about this injury and I hate making decisions….what would you guys do (especially those of you who are as far along as I am) in this situation??????  Is there hope that I can get the ankle to loosen up without re-casting?  Any opinions or advice would be sincerely welcome.  And to those of you told that it is time to weight bear……let my story be a lesson that you need to step on it :)

Happy Healing to you all and thanks for reading :)

Marianne

20 Responses to “20 Week Post Op Doc Appt.- To Cast or Not To Cast? That is the question…..”

  1. screwdriveron 21 Oct 2008 at 5:20 pm

    im 39 years old - but if it was me in your shoes id do the serial casting.
    if you labored those 20 weeks with consistent PT and still no better than 90 degrees , what would make you think you can do exercises yourself that will make it better .
    it is too far off lacking range of motion that you need the ankle strecthed out day in day out in a cast to get the range .
    thats why youll also need the night brace after the casting so it wont revert back in range .
    just make sure you have enough help at home for 6 weeks if you cant function well when in a cast.

  2. walshieon 21 Oct 2008 at 5:31 pm

    “So, here I am now, walking with an extreme limp and a cane, still have pain, and not at 90 degrees.”

    Marianne get the serial casting. IMHO.

    All the best..you’ll be fine in no time.

  3. Tomon 21 Oct 2008 at 8:37 pm

    Marianne - You definitely present an interesting case. I agree with screwdriver and walshie that the serial casting sounds like the best option. Seems like you need to do something to change the status quo. I would say go with the serial casting or try working with a new therapist.

  4. anniehon 22 Oct 2008 at 1:51 am

    I agree with the others, if you are still suffering you should go down the serial casting route, I know this sounds awful to you after all this time, but it sounds like it is the only option.

    Make sure you talk to your physiotherapist their knowledge will be helpful to you, can you talk to another doctor as well just for a second opinion?

    Good luck with your decision

    Annie

  5. MarilynRDon 22 Oct 2008 at 11:25 am

    Marianne,

    Email if needed: MarilynRD@comcast.net

    I vote for the surgery hon….lengthening…and be at 90 four weeks post op (almost guarenteed) if no other complication. Get a second opinion imho. My Doc puts a cast on for first week and then at Day 7 a BOOT at -1 with NO WEIGHT for four weeks post op.

    So sorry you are going through all this….I was on pain meds for 6 weeks and it helped. The increased pain you have had should have said something about the surgery to them …..good luck sweetie! Pain is considered the fifth vital sign…it must be listened to.

    One more thing….what’s the rush now? One week decision? Pressuring you? You take your time sweetie. Ask him if he consulted with another Doc. Ask him how much tendon was removed? Ask him if he wouldn’t mine if you got a second opinion and then ask around. What makes them think that the tendon will lengthen on it’s own in a cast? Just my .02 speaking as someone had the surgery to lengthen my tendon. (Of course I am only 8 weeks, but still…) I would be interested to hear what Dr Ross thinks..

    MarilynRD

  6. Doc Rosson 22 Oct 2008 at 3:38 pm

    Marianne,

    First sorry to hear what you’re going thru. This injury is tough enough and then to throw this extra misery….We’re thinking of you.
    From my experience with similar conditions it is important to get the range of motion back into the joint as soon as possible. That being said we need to restore it….If you have been with the same PT I would suggest getting a second opinion. There are many different protocols to restore mobility and perhaps another PT can come up with additional protocols.
    As far as the serial casting…..It may not have to be a 24/7 approach, a removable cast/boot with incremental ranges of motion can definitely help and allow you some flexibility to remove it, exercise, wash and not feel cluastrophobic.
    Also…Have you done massage, laser, ultrasound, Stim, tubing, etc.??
    As you found out a little hurt now leads to smiles later on. The last thing we want to do is go in and do another surgery…so you’ll need to push conservatively (PT, or cast) up until the 7-8 month mark because after that you may not be able to increase the mobility and have permanent restriction that will require surgery. Thats why he’s pressuring you to make a decision.
    So….List for me the PT treatments you have had.
    Schedule another opinion ASAP with a different PT.
    Ask the surgeon about the removable cast/boot and if that’s an option. Obviously I cannot justify it without doing an exam, etc.
    Become educated, decide what you are going to do and get moving.

    Good Luck and let me know if you need anything else.

    Doc Ross

  7. Matton 23 Oct 2008 at 5:51 pm

    Marianne~
    So sorry you are at this road block. I agree with Doc Ross. A second PT opinon is in order. If you have truly done everything that the PT was asking of you and he/she did not make adjustments to your treatment then I question future effectiveness. ROM is supposed to be the first to come back, then strength. There are a lot of stretching excercises that can be done. My PT has had me doing lots of them and I made it past the 90 degree mark at week 10. Granted, you and I may have different bodies but I think if your PT saw this as an area of concern and wasn’t pushing you harder then you should be disappointed in them, not yourself.
    Just for my own curiosity, what types of stretch specific excercises have you been doing? How long?
    I hope you get the second opinon you are looking for. I’ll be pulling for you!!!!
    Matt

  8. screwdriveron 24 Oct 2008 at 8:56 am

    marilynRD - i pretty sure the doctor would have her do serial casting first , and if it does not work then maybe surgery will be the next option . they try the more conservative means first usually . I mean even the Patriots QB Tom brady was not spared as he got infection in his sugical knee.

    Doc ross - the only serial casting i know is the application of a series of cast usually in a weekly basis while changing the range of motion in increments . i dont know of any serial casting thats removable at any time you please .

    also the doctor would shy away to do a removable boot a this time as the patient can always remove it and not comply especiall when they are weak mentally to endure .

  9. marianneon 24 Oct 2008 at 9:43 am

    I really appreciate all of your well- thought -out comments regarding my frustrating situation and complex decision I have to make– to cast or not….

    Screwdriver,
    Your last comment got me chuckling when you mentioned the “weak mentally” reasoning….I definitely fall into that category!! :( I am having a really hard time thinking about the fact that I will be stuck for 6 weeks with no exercising the ankle. I am afraid of having to learn how to walk all over again after working so hard this time around… If the doc could tell me that I would walk out of the cast after 6 weeks better than I am now, I would be less hesitant. What will happen to the strength that I have gained back in my leg? Will I be a limp blob again? Does a walking cast help keep the strength in the leg/calf more-so than NWB? What if I can get it to 90 degrees on my own? I think I’m losing it……

    Matt,
    I really would like to get a second PT opinion, but my insurance (HMO) only refers to the one I went to:( I agree with you that I don’t think I received the best care and I have been disappointed from the start with their methods of treatment. I too think they could have been more agressive. They gave me a different therapist/aid everytime I came in, and I never consistently was given a thorough massage that really worked the scar tissue which I have a lot of.
    I appreciate you reminding me about the fact that I have done my job…they dropped the ball.
    As for specific stretching exercises, I have used the theraband, towell, while sitting, rocker board, pro-stretch (blue thing you put your foot in and it rocks back and forth), standing against a wall barefoot trying to get my heel to touch the baseboard, standing on wedge to get stretch. I do these things for 1 hour twice a day along with recumbent bike for 20 minutes— All of the above I have been doing at home.

    Thanks everyone for all of your support….any more advice would be welcome!!!!

  10. screwdriveron 25 Oct 2008 at 10:42 am

    marianne,

    going with the serial casting - the doctor might allow you to bear weight on the leg, and might allow you to walk on it .
    about the strenght - that will be the compromise .

    when in a cast - all you can do is isometric exercises where the muscle generates a contraction without changing its lenght with the joint in one position and it is not an effective way to strenghten a muscle in only one range of a joint .

    what you wanna achieve first is a more normal range of motion or close to normal as you can get - then from there strenghten it .

    even if you are strong on your calf muscle and you are less than 90 degrees range avalable - you will still have a limp - even if you can do the sngle leg calf raises with it , the limp will originate from the fact that when we walk we need to bend the ankle to dorsiflexion past 90 degrees about 20 degrees . if you cant do that your body needs to do something to compensate and the compensation will be to do abnormal movements to make up for it .

  11. stevewon 27 Oct 2008 at 8:45 pm

    Marianne-

    I can’t add much more than the well thought out and well written suggestions from the others who responded here but one little thing. Whether you choose the casting, finally break through the PT barrier and achieve the positive results you want, or ultimately end up in surgery, one thing I feel strongly will happen. You WILL feel better both physically and mentally in the future.

    Try not to be so hard on yourself. We are all individuals dealing with a similar situation, but there are so many variables in each situation, that while we can use each others’ experiences as things to learn from and relate to, we can’t totally apply any one experience to our own.

    While I and others have been pretty lucky, you know many on this site have had serious roadblocks on the road to recovery. Even our ATR brothers and sisters who have suffered re-ruptures or wound complications have ultimately either beaten their setbacks or are just around the corner from doing so. I realize it’s not easy and I don’t want to simplify any of these struggles here. But in the end, I truly believe you, even if you lose some battles along the way, will win this war.

  12. MarilynRDon 28 Oct 2008 at 12:45 pm

    steve,

    What a well written and sensitive note.

    Marianne,

    I couldn’t agree more, every situation is different….we are routing for you to continue the recovery that is best for you.

  13. marianneon 28 Oct 2008 at 4:27 pm

    Thanks Steve and Marilyn for your support and advice…..I have postponed my ortho-doc appt. to Thursday, Nov. 6th after thoroughly discussing my options with my DH. I was ready to go for the “serial casting” today, but my husband convinced me to hold off another week on deciding while I continue to work on ROM at home. My husband has been giving my ankle a good massage and stretch, as well, every evening….anyway, something must be working because I have been able to finally get my foot flat on the floor, ‘even’ with my other foot, and can also now stand against a wall with both my heels touching!!!! It’s quite a stretch, but I couldn’t do that a week ago… My PT said once I could do that, my ankle would be at 90 degrees :) Anyway, I have noticed progress in the past few days, able to roll onto my foot more and less of a limp….
    I know that I am healing, albeit at a slower pace than most, so I am going to keep working at it and see what the doc says next week. Keep the good vibes going guys and all of your input has been greatly appreciated.

    Keep healing everyone :)
    Marianne

  14. walshieon 28 Oct 2008 at 7:31 pm

    Great news! Keep it up!

  15. marianneon 28 Oct 2008 at 7:55 pm

    http://www.youtube.com/watch?v=Z6vxFuvY4kk&feature=related

    This is hysterical!!!! I found it on Misty May’s blog site. Someone posted it to cheer her up. The guy is crazy!!!!! Take a look….pretty funny stuff!

  16. marianneon 28 Oct 2008 at 8:01 pm

    Thanks Walshie!!

  17. anniehon 29 Oct 2008 at 2:40 am

    Wow Marianne,

    Don’t know what he is taking but I want some of it. How does he do that. Just goes to show what you can do when wearing the boot!!

    Would love to know how he is now. Great find.

    Annie

  18. Sanfrantourguideon 03 Nov 2008 at 5:49 pm

    Marianne!

    What decision did you make? You’re leaving us hanging in suspense here! I am starting Week 20, too, so your case interests me. I have been walking with a slight limp, comes and goes, and never did have any therapy; doc said not necessary.
    I would really like to know your decision, or if more therapy helped.

    Mary

  19. marianneon 04 Nov 2008 at 12:26 pm

    Sanfrantourguide,

    Scroll up on my blog (where you posted) and you will see what I decided…..I plan on posting after my ortho doc visit on Thursday…I am hoping for good news from him . At this point, I have more ROM and can get my heel flat, although it still feels very tight when I do. I also walk very slowly because if I don’t my limp is worse….my back is not to happy with my gait either ;(

    I plan on writing an updated post after I hear from doc. on Thursday.

    Wish me luck!!!
    Marianne

  20. Sanfrantourguideon 05 Nov 2008 at 11:09 pm

    I do wish you luck! I have been really lucky and lazy - I try to stand up on my toes in spare moments, but the ATR heel raise is far from there. Still, I am not sweating it, just letting it heal slowly. So congratulations for your recent progress!

    My latest investigation online is whether Lotensin, the ACE inhibitor, can cause tendon troubles, or the diuretic HZT. I was put on these last November after a physical, kept them up three months, then stopped. So my conviction remains that the ATR did not “pop” out of nowhere, that something weakened my tendon, and that a healthy tendon would not rupture.

    However, I could be wrong! My old cranky surgeon said that in my case, it was just plain dancing and banging the foot around, simple case of too much stress on it. I hope he’s right! Raw foods, brown rice and vitamins now - getting hypertension under control naturally; I don’t want to take meds again.

    Mary

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