morcs’s AchillesBlog

Trying not to contract the calf

I remember at first, when I was in the cast, I was pretty scared of accidentally contracting my calf muscles. In my mind, if it was stitching back together, it would only take a small amount of force to pull the ends apart again. What if I twitched in my sleep?

As the days went by though I began to obsess over the opposite question - what if they’re not joining together at all? I really wanted to contract that calf just gently to see if it caused anything to happen below the rupture site.

When you see images like this it seems baffling that just fixing the ankle downwards would be enough for the ends to meet up properly and join back together.

(I’ve since learned that the tendon is housed in a sheath, I guess that helps keep them lined up. Still seems pretty incredible to me!)

I couldn’t resist testing it, and I found that I could gently press the “pads” of my feet against the bottom of the cast, which was reassuring…Until I remembered that on the morning after I’d ruptured I’d tried exactly the same thing with the same result. That first time I thought maybe this meant it was only a partial rupture, the consultant later pointed out the obvious gap between the tendon ends.

I think what I was feeling was other synergist muscles (posterior tib or peroneals?) contracting, as the pressure was all on one side (I can’t remember which side).

I kept on driving myself mad trying to prove that I could get pressure across all the “pads” and feel the contraction in the main calf muscles. I think I could, but it took a lot of concentration.

Is this thing actually on!?

As time went on and I got into the boot I started to get a bit more confident about trying to contract. But now what I found was - I couldn’t contract it! Has my brain switched it off to protect it, have I just forgotten how to do it? I find this really interesting!

If I really concentrated I think I could contract the soleus muscle, but the gastroc was just hanging there limp.

Physio

Now my physio has asked me to do some very minimal, 5 second contractions twice a day but only with the leg straight and the foot in full plantar-flexion/equinus (out of the boot).

I’m still finding it very difficult to get any obvious contraction in the gastroc this way. She did demonstrate the movement to me but I can’t remember whether my foot was hanging off the end of the bed or not. If I do have my heel pressed against the floor I feel I have more to fight against and I can get a bit more of a contraction, so I guess that’s the way to go. Otherwise it feels like I’m not really achieving anything at all with the exercise.

Time to take another wedge out, so I’ve hit the top or bottom dilemma again.

Starting with wedges 2 to 5 (where 2 is now the top wedge). I tried removing number 2 first, but it didn’t feel right. The lip of the 3rd wedge was now under the arch of my foot. I didn’t want to mess about too much as they’re only stuck together with little sticky pads which I can imagine losing their stickiness, but I had to try the alternative. So I put the 2nd wedge back on, pulled the whole lot out and removed the bottom wedge instead. Much better! So I’m now using wedges 2 to 4.

It feels about the same as before under the foot as you’d expect, I’m still standing on wedge 2. It’s more comfortable on the top of the foot though. Now that the whole foot is lower there’s more room to play with under the boot straps.

Like before I felt a bit of a tug on the tendon as I walked so had to use the crutch a bit more to start with, but that didn’t last long.

I also took a picture of my legs whilst the boot was off, just thought it might be interesting to record how much the left gastroc atrophies over time. Excuse the hairy legs.

Today I got to meet my physio for the first time. She explained there’s not much we can do until I’m out of the boot, but I got some basic exercises to do and a lot of useful info.

Stretching?

My ankle dorsiflexion (i.e. pulling the toes towards the knee) is still pretty limited. When I take the boot off I find I can get to somewhere between the red and orange lines in the picture below before I feel a tug on the tendon. I’ve been wondering if it’s worth gently stretching the calf in order to try to get that range of motion back…

Today I learned I should NOT to try and stretch the tendon. At all!

No stretching then

The way she explained it was to think of the gap between the tendon ends as a pothole in the road. Essentially my body has done a quick cowboy repair on the pothole, filling it with rough gravel and tar (scar tissue) just in case I need to use it to run away from a lion or something. The proper job of laying nice fresh tarmac (collagen fibres?) and smoothing it all out takes months and can’t be rushed.

If I try to stretch it now, I could end up with an elongated tendon. The problem would be that when the calf muscles started to contract, they’d just be reeling up slack in the tendon rather than doing their job of pulling on the heel bone and lifting weight.

There would then be a limited amount of contraction left in the calf muscles to actually move the ankle. I’d end up with permanent weakness in push-off and landing on that side, and probably pain in the calf muscles from having to remain contracted all the time.

Mobility exercises

Six times a day I should get my foot out of the boot and move the ankle the following ways

• Plantarflexion
• Dorsiflexion (As much as I can anyway, and very gently, no stretching!)
• Eversion
• Inversion

I think basically these are to ensure my ankle stays mobile and doesn’t seize up through lack of use.

Strengthening exercises

Twice a day I need to get out of the boot, lay my leg out in front of me, and at full plantarflexion (so toes already pointing away), try to contract my calf for 5 seconds at a time, as pain allows. 2 or 3 reps at first but I can build up adding one rep at a time as long as it’s not painful or swollen.

If it does cause pain/swelling that’s fine, but I need to skip it for the next day to allow recovery before hitting it again.

I think this one is try to stop my calf muscles wasting away completely and to encourage the tendon to build fibres in the right alignment for a strong repair.

The good leg

We also talked about the importance of looking after the good side, as it’s now doing extra work and it’s already starting to feel bad again. So keep stretching that one and doing balancing exercises, one-legged calf-raises etc.

She agreed that I’ve most likely got some bio-mechanical/movement issue that’s damaging both tendons and has led to this result. Obviously I want to try to avoid snapping the other side as well.

I’ve now been in the boot for 1 week. This means it’s time for me to remove the first of the stack of 5 heel wedges. I need to decide which of the wedges to remove. Should I remove the small one at the top of the stack or the large one at the bottom?

Excuse the sock fluff, it’s embedded now!

Unfortunately there was split opinion in the hospital when I was fitted with the boot. The junior consultant thought top, the nurse thought bottom. I thought bottom. The senior consultant told me it was up to me based on whether I had a high or a low instep. We both agreed that looking at my foot was no help - I have a medium instep. Should I just toss a coin?

This thread suggests top: http://patient.info/forums/discuss/heel-lifts-in-airwalker-boot-257684

I went with top.

First impressions - at this new angle I can feel a slight tug on the tendon when I put my weight straight down on it, so I must be right on the limit. With this in mind I’ve done the top of the boot up completely snug so that I don’t get any extra movement as the boot rolls forward. I’m probably going to go back to two crutches for now just to protect it.

On a positive note - the heel is much more comfortable now, it doesn’t feel so much like I’m standing on a large pebble all the time. I think top was the right choice, this time around at least.

I think I might still take from the bottom at some point in future, as my foot is basically the same length as the bottom wedge. If I end up with just that wedge surely the purpose of the wedge (lifting the heel above the forefoot) is lost. Maybe when the wedges above it are removed there’ll be enough overlap to give it an angle still? Plenty of time to work that out!

After 5 days in the boot I could get around our flat with one crutch, though it was pretty awkward. With all 5 heel wedges in there’s a big height difference compared to the good leg.

We’d walked to the gym that night which was pretty normal for us, I figured walking to the gym might help my problem calves loosen up or something, clearly not!

Thankfully a friend (the coach’s girlfriend/physio from the previous post) had given me and my girlfriend a lift to the hospital. She stayed with us and kept any eye on my leg - I think checking there was still bloodflow and telling me to stop trying to move it every time she caught me trying to test if - yes it’s still busted.

A&E was busy. The girl on reception noticed I was pretty pale so offered me a sick bucket. The triage nurse seemed to agree on ruptured tendon. I think she said she knew what I was going through as she’d done it herself. I was given co-codamol for the pain which did the trick (after making me want to puke again for a while)

I think it took nearly 4 hours to be seen, coach arrived with burritos and took over from his girlfriend, staying to give us a lift back. Nice to be well looked after!

Once inside I could hear that the doctor was having to run around between me and about 6 other different people. Amazing how these guys keep going. After going through with me what had happened he got me up on a bed and had a good squeeze around the leg. There was no pain anywhere he squeezed around the ankle bones/foot but when he got to the back of the leg I remember yelping out in pain (apparently they could hear it outside) despite the codeine.

He got me to try to push my foot down against his hand but I just felt my calf feel like it contracting into itself whilst my foot barely moved. He kept telling me to ignore the pain and push through it, I was really pushing but it just felt like my calf was trying to retract into itself and nothing was happening at my foot. I remember I was laughing and joking as I was wheeled in so he probably had to make sure I wasn’t exaggerating or something!

After the doctor had consulted with another hospital over the phone I was given some crutches and sent for X-ray to confirm I hadn’t detached any bits of bone with the tendon. All bones intact but they could see a lot of something going on around the tendon.

I was put in a plaster cast “in equinus” (with my toes pointing down) and sent home with an outpatient appointment to see the consultant in the fracture clinic/orthopaedics the next day.

It wasn’t until after I’d got home (and my coach had helped carry me up the stairs) that I realised the back of the cast was soft! Apparently this is called a backslab cast and is done to help with swelling whilst the rigid front keeps the ankle in the right position.

On the 22nd of December 2016 - I suffered the full rupture of my left Achilles tendon.

The first thing people always ask me is: “What were you doing?”. It’s hard to describe, so I use a picture (the one on the right):

I don’t think the exercise was the main issue though. I’ve been having problems with tightness and pain in my calves and Achilles for years now. Despite endless stretching exercises it’s never really improved that much. I think it could have been any movement that involved landing on the toes that caused one of my long suffering Achilles to finally give up.

As I remember it there was a loud snapping sound and it felt like the guy behind me had booted the back of my leg as hard as he could, causing the leg to collapse. As I fell I knew (from researching online about my calf problems in the past) that this is what people usually report when the Achilles snaps. I also knew that probably meant a year of recovery. I felt pretty sick and started to get tunnel vision. I guess that was a combination of the pain and the shock. I think the first thing I did was ask for a chalk bucket in case I barfed!

Fortunately my coach’s girlfriend, a physiotherapist, was in the gym at the time. I think she heard the noise over the top of the busy gym and came over. “I think we need to get you to A&E”.