mrboro’s AchillesBlog

Second surgery progressing. Stitches out today, no infection, healed and looks good. Back in boot 24/7 and still no weight on foot but I am thankful for the smallest progress. I even managed shopping at Wal-Mart on knee scooter only there a little while but first time in a while since I have been in a store.

Oh by the way. Norm, I’m the same age as you. After playing Rugby for 25 years, sqush for 15 and keeping fit generally, the ‘mental’ side of an ATR has been the most difficult part: without saying, yours particularly, and other posters positive remarks have helped considerably. Thank You.
Anyone else out there with a similar recommendation on a rare failed healing process ? P.s. 40 degrees (C) and sunny here today, not much chance of ice covered steps in Dubai !

Roger G, good to hear from you. Alas, I’m still willing to bet against the outcome we’re all hoping for. I do agree with the comment about the timing, though there’s something to be said for getting ‘er done and behind you.

Also, while you’re AT-impaired, you should be able to use my “trick” to get down the stairs “normally”. I’ve posted it ~20 times, including on a fairly recent blog page of my own. Short version: plant your “bad” foot, pointing straight ahead”, about half-way on/off the step, toes over air. Then as you step past it with the “good” foot, next stair down, let the “bad” one roll over the nose of the step. As long as you’re careful and consistent in your foot placement, and not walking on ice-covered steps, you should look and feel pretty normal, even with zero df rom and very little pf/AT/calf strength. Works in a fixed or hinged boot, and in shoes.

CG, I don’t think there’s much routine “regeneration” happening in a normal healthy AT. For one thing, there isn’t much blood flow. OTOH, there are a number of phases to ATR recovery, virtually identical with or without surgery. The first “glue” that binds the ends together is not the ultimate strong sinew that will be there in a year or two. But that’s in a normal recovery, not one where the torn ends are left to heal separately and left mobile (walking), so the gap size keeps fluctuating. In that situation, I’d expect the two ends to heal as ends, not as a would-be connection. Shoving them together with a boot or cast wouldn’t make them grow together any more than closing your fist makes your fingers grow together. But if a surgeon trimmed off your fingertips and stitched them together…

Hi Norm
Quite a time since I’ve posted; all after my unsuccessful conservative treatment. Your advice at the time, after 9 weeks in caste/orthoboot and still 5 cm gap (!) was to go for.the op. my orthopod and physio thinks that I can manage without the knife. Apparently I have a very strong Plantar tendon, which together with scar tissue will hold it all together. Three weeks out of boot! I am walking with a slight limp and have two weeks in Dubai, so aqua exercise in pool could prove them right or wrong ! The only problem I have on mobility is descending stairs, which are a sort of sideways effort, but getting better. I also have swelling, particularly front of ankle which I ice to good effect.
My orthopod, a specialist knee and ankle man says that time scale for op is now irrelevant; so if I want the op, say next year (when I have less pressing time issues) it makes no difference now.
RogerG

@norm

This is the second time I’ve heard someone say their doctor suggested a non-op approach on a “stale” ATR. I’m trying to see the logic in this, or if there is any.

Do you think it’s possible that they’re hoping for a partial heal of the tendon that will ultimately lead to a fuller regeneration? I’m wondering if the tendon regenerates continuously long after the ATR. So perhaps they’re hoping that two parts of the broken ends can connect, and over time and use, the gap will continue to fill in. Is the tendon something that perpetually breaks down and recreates itself?

For example, lets say a person has a less than ideal tendon healing at 8 weeks in the boot. However it is connected and they pass the thompson test. Will the actual quality of the connection continue to improve over the long term? Or is the quality of the healing pretty much set forever once it’s healed?

BTW, I’m shocked that some doctors still try the non-op approach on totally “stale” ATRs, like yours after 18 months! Even 3 or 4 weeks after and ATR, I’d bet against any non-op treatment succeeding, because the window of opportunity has closed. I.e., the time of rapid and massive inflammation and healing and regeneration has passed. The trauma of surgery — having all the tissues, including the ends of the torn AT, cut with a scalpel — starts the clock running again, and opens that window.

I am a HUGE fan of non-op treatment of fresh ATRs, based on the excellent results from recent studies using fast, aggressive, and convenient protocols (like bit.ly/UWOProtocol from Canada). But slapping somebody in a boot who’s got an 18-month-old ATR is just a dumb waste of time, IMHO, no matter the age of the patient.

marltom, I’m the same age as you, so you’re young enough to become an addict here — watch out!! Lots of people who blog here have never done it before.

Here are the instructions from the Main Page:
“To create a new blog, please create a user account first. [I think you've done that. -NotN] And then, please send me an e-mail (achillesblog@gmail.com) from the e-mail address that you registered with, and I’ll create a blog for you. Please tell me what your username is, and mention briefly how your injury was caused.” After Dennis does his magic, you’ll have a “vanilla” empty blog headed “Hello World! by marltom”. Then you get the fun of editing the “vanilla” text into your own story. (Heck, you’re not GOING anywhere. . . )

I’d expect the results of your second surgery to be as good as your first, and — we all hope! — longer-lasting.

I had walked on a ruptured achellies tendon for 18 months, they tried a boot and PT and said I just had to live with it. The main reason being my age 67. My Dr. sent me to this Dr. he is wonderful but he said there was a huge gap and complete repture. I am not very good at the computer so I do not know how to start a blog. This time I have a knee scooter and have decided I need driving lessons to get around. I know this will pass. Thank you

Sorry about that, marltom! I don’t remember your prior details, sorry. Do you have a blog of your own? If not and you’ve got some time and energy, start one, and catch us all up (again). If you had screws, then I guess it was either to fix a Haglunds-type problem, or to reattach an AT that had pulled off the heel bone. Bummer about the screw. When things go well, nature’s healing is a miracle, but when your body starts doing the healing around a loose screw, it’s not what you need.

Your successful rehab and PT last time will probably stand you in good stead this time, too — less atrophy, good attitude, you know what to expect and how to Watch Your Step, etc. Good luck!

Just had to have a second surgery mon. It was suppose to be minor, clean out the small wound that has not healed for any length of time during the past 21 weeks since surgery. When the Dr. got in there he found a screw lose, lots of scar tissue. He ended up opening the whole scar. I am back completely off my foot for at least 4 weeks. I had been doing so great, doing wonderful in PT . I was able to wear 2 shoes and climb stairs. This is such a set back..

Sorry to hear you are having problems, I am now almost 2 years post op and had a similar problem to yours which required additional surgery. I took high dose Antibiotics for 6 weeks to no avail. The reason was that while the infection was being killed off, the suture kept poking back thru the skin. When the surgeon snips the suture if he cuts it at an angle then this creates a point which inventually finds its way to the surface leaving a route for infection. The only way to cure this is to have the suture removed. After my op which took about 5 minutes the wound was packed with wadding and dressed on a daily basis for about three weeks. I then had no further problems and went on to make a good recovery.

Hope this helps and you are soon on the way to a good outcome.

Andy

@garrettcox,
Similar case to yours…I’m 11 months post op and I still cannot do a decent/full single heel raise. However, I can do many in the swimming pool, and I do notice some progress, albeit very slow.
I also had wound healing issues, but they resolved much earlier and well before I went to two shoes.
About weight training, I went back to doing legs at 5 months post op. I was in excellent shape at the time of my injury which helped. However, I am not back to the level I was before the ATR though getting stronger as time goes by. Like you, I tore my left Achilles, so the overuse on the right leg has brought me a serious case of tendinopathy, some pain in my right knee, and a lot of pain in my right Achilles. For this reason I have modified my calf workout. I only use weights on the operated tendon, and I go for high reps. No weights, only eccentric contractions with body weight on the other tendon. A strong calf muscle pulls harder and could rip a weakened tendon…Last thing we need is another rupture!

9 mo out of surgery.

I’ve had many problems with my incision site. I live in the desert it is very dry. Like skin on a knuckle, when I started weight bearing my incision came open and 3 different spots. The top half has healed nicely and so has the bottom couple of inches. But there is a region about 3 1/2 in in the middle that had the hardest time healing.

I’ve seen my ortho, primary, and even a plastic surgeon. None thought it was infected. It didn’t hurt too bad. My primary doc shot me up with some antibiotic which seemed to help.

Still can’t do a single leg calf raise at this time despite 2 mo. of weight training (mostly leg). Started very small and am now almost back to my full strength in squat, leg press, and leg curl etc. The calf exercises I take very slow and and having problems with the single leg calf raise. I feel like my foot isn’t strong enough to get it off the ground but maybe a 1/4 inch.

Anyone else this far along in the process having these problems? Please help…

Cheers Pauls, much appreciated

Hope you get this sorted ASAP and back on the road to recovery. Good Luck, I am just over 3 weeks post surgery, so fingers crossed all ok so far

Thanks gkraemer14, hope your recovery is going a bit smoother then mine!!

Hey Boro, You and I are on a very similar timeline. My wound started spitting out sutures pretty early, around 5-6 weeks. Sorry to hear that you’re having trouble. Hope everything gets taken care of.

Thanks for your comments Andrew1971, I really appreciate it

So sorry to read this set back, I don’t have any words of wisdom only to say that knowing how much of a timesink goes into getting back to normality without the complicatins, I really feel for you and I send my best wishes for the easiest route to recovery

Hi Sheena, thanks for your comments. Hopefully the infection will be cleared by the antibiotics. If this happens, my op will be relatively minor to snip the suture back. It’s an open suture which is connecting the tendon, hence it can’t be taken out only snipped back so it’s ‘under the skin’. If the infection can’t be cleared or is under my wound, I’m looking at more extensive surgery.

Thanks for your thoughts on IV antibiotics, I think I need to raise this as a means of trying to kill the infection……

Oh No what a nightmare!
Are you in the UK?
Do your docs think there is any chance that the infection will go just with the antibiotics?
I really hope it does, the thought of going through it all again is grim.
Is there any way at all you can avoid surgery again, if there is a slim chance, personally I would push for that. what about IV antibiotics? If the suture has come out of the wound or is it still partially in there?

Houseman - thanks for your comments. I believe I had my tendon stitched without any augmented tendon. It’s an interesting thought and I need to check this to make sure!

Did you get your tendon augmented with the plantaris tendon? If yes, this will cause some soreness and irritation as the augmented tendon will have show some “lumpiness” and will rub against regular shoes.

Thanks normofthenorth…. I’ll have a trawl of the old blogs to check the experiences of GerryR and others

In addition to missed surface sutures, we’ve had a number of folks here who’ve had deep sutures — maybe mostly the supposedly dissolving kind? — that caused problems. GerryR comes to mind, but there have been 1 or more others since. Check the surface ones first, for sure. Most simple tissue healing happens in about 6 weeks, I’ve been told…

Kenstar 2 - Thanks for your comments, much appreciated. It confirms my suspicions. I think I need to get it checked as soon as possible. ….

Definetly a possibility that a suture may be within the wound. My doctor removed my stitches in week 3. He removed all but right before he cleaned it he noticed 2 more when the light hit it. Then he removed the remaining. Hope all is well and your discomfort subsides…

Thanks for your comments jeniferanderson, beralic and starshep!

I’m trying really hard to avoid any sideways motion and keeping to very short (flat footed) forward steps. I started PT about 2 weeks ago, my foot movement downwards is ok but I can only get to around 90 degrees on my up movement. It’ll be a while until I’m pushing off properly!!! Starshep, I think your PT is doing a good job from what you’ve said. Mine is less strict but follows the same principles.

Good luck all!

Jason:

Are you scheduled for any physical therapy? I’m about 6 weeks into mine and it sometimes shocks me how much goes into walking and how much I took it for granted before this injury. To me it is important to progress at a proper pace and rebuild the strength in your legs and flexibility in your ankle before trying to progress too far and too fast. Once you build those basics back up, your confidence will follow. My therapist is a stickler for getting the walk technique down which includes a lot of factors. Hell, he even wants me to get my hip motion right. What do I know about hip motion when walking, I’m a guy. LOL

Congratulations! The 1st bit is the hardest and a lot of it is about “the mental game” yeah it feels scary, but pain will guide you, don’t try and go too fast and you will be fine, it takes quite a while to be able to “push off” at the end of the stride, try to walk “normally” though without turning the foot out to the side too much, just take lots of shorter steps good luck!

Congrats!! I started taking my first steps on Monday. Very scary, isn’t it? Keep at it and watch your step!

Hi kimjaz

Thanks for your message

I experienced no pain from the actual walking but my foot still feels tight across the top of the ankle and the actual wound is a bit sore/sensitive from rubbing from the walker boot and trainers. My major issue is the mental side of putting full weight on my foot. I’m not ‘pushing off’ from my toes yet to ensure my achilles isn’t under undue pressure until I’ve built it up a bit. My walk was a bit flat footed like a babies!

Congrats! Did it hurt at all at PWB or FWB?

DJ, it’s not hard to walk in a hinged boot that’s locked in a plantar-flexed (toe-down) angle, either. Fiberglass “walking casts” are also similarly toe-down, and made for walking. It’s often better with a “cast shoe” to add a rubber sole, and a similar gizmo on the other foot to equalize the height.
If you’re “hobbling around” without crutches, then you’re not doing PWB or 25#, you’re doing FWB. And if your “hobbling around” (with or without crutches) is a toes-to-the-side hobble, then you should stop before you hurt yourself — probably not your AT, “just” the rest of your body! Ortho boots and walking casts are all designed so you can walk on them with your toes pointed straight ahead. Land on the heel, then roll straight forward over the gizmo on the rounded sole. As you move forward, the load that your AT-and-calf would normally bear, is borne by the gizmo and transferred to the front of your shin. For PWB, that’s only a fraction of your weight, the rest taken by the crutches; for FWB, it’s all of it, no crutches.

The various estimates of % FW or pounds are just guidelines. The important thing is to start with ~0 weight, a

DJ - ha - yes that is the question - how do you know when it’s 25#. He told me to practice with a scale to see what it feels like. I didn’t do that but just tried to only put a small amount of weight on the leg at first while using 2 crutches, and then very gradually increasing it over the past weeks. I haven’t done too much to work the foot yet, other then wiggling it a bit when the boot is off. My next appt. is on Tuesday - I assume I’ll be sent for PT after that. My calf is smaller, but not horribly so. What I’m really looking forward to is being able to drive again (I have a right ATR).

Thanks.
How do you regulate 25# of weight bearing?
I just hobble around with my boot on.
I have been doing circle with my foot with the boot off since week 3 and also flexing my calf muscles.
I do heal raises when sitting down a a few times
A day when the boot is off also. Lost tons of size on my calf. Leg muscle is ok but lost some. I am 40 and spend 3-4 days a week lifting heavy weights. Never stayed away from
The gym this long is 15 years.

Well, speaking from my experience - I am at week 7 as of Tuesday, non-op. After 4 weeks in a cast plantar flexed, my doc put me in a fixed boot at neutral, PWB at 25 pounds of WB. I’ve been gradually increasing the weight on my bad leg in teh past 2 weeks, and in the past few days am only using one crutch (and the boot at neutral). So it seems like you might be able to go to neutral? I will say that my tendon was sore the first day I was put in neutral, but it’s been fine since then.

I think he means what I meant about walking. If their in the Don Joy boot the foot would be angled down locked so impossible to walk. If it is the other boot thats flat with heal lifts in it but the boots flat = able to walk.
I will hit week 8 this Friday non-op. been weight bearing PWB since week 3 and pretty much Hobbling around the last 2 weeks fwb sometimes crutcjes alot of times not. My Boot was at 15 now 7.5 the past week. The doc and I don’t see eye to eye and I want to go to neutral this week. Anyone anyone???
Week 8 neutral??
He wants me to wait until week 10. Then stay in a boot until weeks 12-14.

Julias, your “My foot in the cast is past 90 degrees, so can’t bear weight even if I want to” does not compute. The UWO study patients started WB at 2 weeks, while they still had 2cm of heel lifts in their AirCast (fixed, neutral) boots. Then FWB at 4 weeks, and the heel lifts stayed in until 6 weeks.

Many of us have started WB and walking before we got our ankles to neutral. It’s not a fully natural walking gait, of course, but walking in an orthotic boot usually isn’t. Building the other foot/shoe up to the same height as the boot makes it much more natural — and safer for the rest of your body, too.

Happy healing to you, too. I’ll see what happens with the crutches.

Thanks for your comments Julius! I’m very much still at the crutches stage (just over 6 weeks post op). I can hardly imagine walking at the moment. My ankle is swollen and I’m just getting a very small amount of movement. My Physio starts on Monday so I hope things start to improve soon. Good luck with your recovery!

Glad to hear the comments about the boot. I get mine next week. I’ve been in a cast for 3 weeks after being in a splint for 2. So I’ll be 6 weeks post op by the time I start weight bearing. Very scary to start walking again, but I’ve almost fallen a few times on the crutches so at least that fear of falling and re-tearing will be gone. My foot in the cast is past 90 degrees, so can’t bear weight even if I want to. How soon have others been able to ditch the crutches?

Janus! That’s a very amusing thought….. I’m sure all the Velcro on the boot can be used to good effect!

I took it off at night. If you toss and turn a lot in your sleep, then maybe leave it on. But I think you’d be okay. Not likely to overload the healing ankle/tendon in bed — unless you and a partner are trying kama sutra variations, in which case all bets are off and the boot although a hinderance might even be required.