niewneon’s AchillesBlog

Humbled by Reality, the “gradual approach” is less gradual after all.

Went to 2-shoes today, exactly on the 6 week mark.  Had been wearing the boot until today but actually less and less.  The reason was that it gave me serious back pains due to the unevenness and resulting crookedness of the back. Despite back exercises, stretching and all that I simply wasn’t able to function. So, about a week ago I started by taking the boot off at night, then a few days later I limped around the house with no boot. Big difference for the back - due to the limp still some unevenness but at least that seems curable with back exercises.  I am being really, really careful with the foot of course, not taking any (unavoidable) risks.   When walking around in the boot I had actually used the “ROM” mode with increasing freedom over the last few days and started to exercise the calf/tendon by pushing for example while driving.

For the moment of the 2-shoes I bought these:
www.schuhhaus-rempp.de/poelking_gross/680255_1.jpg

Also, these:
www.bauerfeind.com/de/produkte/bandagen/fuss/achillotrain-pro.html

And alternatively these:
www.sporlastic.de/de/main/7_fuss/07071.html

Then, I got one of these:
www.betterbraces.com/donjoy-velocity-ankle-brace

But the PT thinks I don’t even need that, so I might wear that only in “high risk” environments - which I don’t know yet what those are. Unfortunately it might be one of those things one might find out only when it’s too late. Anyways, they don’t really support the AT specifically and actually require a lot of doing to get fitted and into a shoe. I might experiment with that a little more if I find the time and energy, of which I have very, very little lately.

I have started to exercise on one of these:
www.freemotionfitness.com/fitness/en/Commercial-Fitness/striders

It’s more involved than I thought, I have never used these machines as I rather believed in “natural” sports like running etc. Just getting the hand/foot coordination right is not so intuitive actually.   After about 20-30 minutes on that, I feel the leg tire considerably and call it a day for now.

Having PT every weekday. Includes “scar tissue” massage which is quite painful but actually feels “satisfying” in that it does feel to me like it would prevent adhesion and greatly improves flexibility of the foot. After that, a strider session and some Theraband, the leg/foot/ankle/tendon is seriously ready for sleep. OK, also walked for about mile, that did tire the leg as well.

The upside of all this commotion is that it feels great to move again, back pain is seriously reduced and life is coming back!

The recovery timeline form the moment of ATR for me was outlined by the hospital like this:

• Surgery immediately, in my case within 3 hours of ATR, around 10pm,
  2 inch incision on the inside of the leg, not the back. The tendon ends were cut straight, then sewed together with
  a slight overlap. If I understand correctly that is slightly different from the “suture” based method
• Fitted with Vacoped at 30 degrees plantar flexion as part of surgery, woke up already wearing it
• 20kg (44lbs)  weight bearing the next morning, crutches fitted, was shown how to walk stairs
• One time “lymph drainage” which is a very gentle massage in order to move fluid away from foot around noon of my one full day in hospital
• Release from hospital at my own wish the next day after removal of a little drainage tube which hadn’t really done a whole lot in the first place
  (there was maybe an espresso cup worth of blood/fluid, most of which seems to have drained before I had even noticed I had that thing)
  They would have kept me in the hospital for one more day but I didn’t feel sick enough.

  Schedule:

• PWB (20kg) for 4 weeks
  FWB for 2 weeks
  2 shoes from week 6
• 30 deg plantar for 2 weeks
  15 deg plantar for another 2 weeks
  0 deg while FWB
• Removal of stitches around end of week 2, I had it done after 10 days
• I am only supposed to take the boot off for washing and “lymph drainage” in case of swelling
  (which I didn’t have much)
• I am supposed to avoid all movement and forces on the foot whatsoever (except the 20kg PWB) all the way until 2 shoes
• Absolutely no walking around, shower standing up or anything like that without boot on
• Two visits to the hospital, one after one week, the other after about 3 weeks, very loosely timed according to my own schedule rather than rigid medical milestones. Basic few-minutes check, look at scar, feel the tendon, nodding head, answering questions, nothing special
• Daily self-injection against thrombosis from lack of movement.  Sounds bad but is actually not a big deal at all, more of a nuisance. (And I am seriously no hero when it comes to things like that)

I have been following that schedule quite strictly apart from a few “wiggle toes while laying on the bed with leg straight up” exercises.  What to me felt like huge movements of the toes was actually barely visible, though.   Especially Normofthenorth on this forum made me think about this (thanks!) as it seems quite a harsh regimen. Very aggressive on one side, very conservative on the other.

So, I started to to modify it slightly:

• Instead of jumping from 30 to 15 degrees, I moved by 5 degrees on consecutive days. I found each move somewhat noticeable
• Instead of jumping from 15 to 0 degrees at week 4 (which is now), I have been moving by 5 degrees on each second day. These moves are actually quite more noticeable than the previous ones which geometrically makes sense as they are actually bigger moves for the tendon
• Instead of going from PWB to FWB in one hop by throwing away the crutches, I start by carefully applying more and more weight while standing up and trying to take it more and more easy with the crutches. I find it pretty hard to get myself to do that in fact. Seems like the body has already unlearned using the left leg. Scary. What would happen after a REAL injury??
• Wiggling the toes - sorry Doc, when I saw how little they actually move, I really can’t see how this little pleasure should do harm after several weeks. If the tendon cannot take that by now, how am I ever supposed to walk on it again??  Interestingly though, even slight toe wiggling I can actually feel in my calf

I am planning to do the 2 shoes transition also much more gradual than the proposed regimen

• After week 6 (2 shoes time) I’ll take the boot off at night
• During daily activities I’ll wear the boot but set to “ROM” mode (flexible angle) with gradually more flexibility over time
• Elliptical cross trainer for relatively safe, mishap free workouts with or without boot later. Planning to do at least 1-2 hours per day on that
  to get back in shape without risking problems with the tendons as that should be slight but very controlled movement and force on it

PT from week 4 onwards, no set schedule and plans here yet

The reasoning for this approach is this:  There is a lot of data about different approaches, some of them quite radically different. Data on results is somewhat inconclusive, the common thread I can see is this:

• The tendon obviously needs to heal, since in normal use it transmits HUGE forces (12 times the body mass), it needs to be seriously strong to withstand those.
• Tendons heal/grow very slowly, much slower than for example muscles
• Forces from slips, jerks and other mishaps are substantially greater than from controlled, carefully planned moves, thus re-reuptures often happen from accidental scenarios.
• Sometimes the tendons seem to attach erroneously to surrounding tissue like the skin of the leg, presumably when everything is too immobilized
• After some healing time the tendon seems to need a little bit of stretching and flexing in order to “learn” what to do and how grow stronger
• Inflammation can occur - presumably by “overdoing”, too much rubbing of scar tissue etc.

So, to sum up, with my gradual approach I am trying to find a compromise taking into account the above points and most of all, avoiding risks of re-rupture or inflammation. I assume that by pain my body is telling me when I am doing something which I shouldn’t, so I am carefully pushing slowly as long as there is no pain or serious discomfort. We have learned that the tendon itself doesn’t seem to feel any pain (at least mine) so I have to take that into account. On the other hand, of course little stings or tickles are probably normal when things get moved for the first time after weeks of immobility and being cut and stitched back together. Patience, young Skywalker!

• Used to be quite active in my childhood, playing Tennis, Field Hockey, Ice Hockey, Ski, of course lots of daily bicycle (growing up in Germany, daily form of transportation), Football (the “soccer” kind), Volleyball, Sailing and various weekly sports activities in school which I always enjoyed like Handball, Basketball etc.
• Was never much of a runner, neither very fast nor very enduring,  in all of those sports activities I focussed more on technique. I have always been on the heavy side, not in a fat but an overall strong way, 183cm/6ft and about 90kg/200lbs
• One year, as a 16 year old foreign exchange student in California, I played “soccer” very competitively in the high school team and a separate league. We had daily practice with lots of running and endurance, I was in quite good shape during that year and became a decent runner
• At age 18 I tore a ligament in my left foot on the stairs at home (trying to rush to Volleyball practice)
• After end of school (Gymnasium in Germany) I slowed my sports activities way down as I had to focus on University and family
• Family, University and eventually job became so involving that I stopped practically all sports activity
• Around age 40 I became sick and tired of a slowly fattening, lumpy, ugly, lazy body and started back into sports, first sailing and skiing
• Around age 45 I started Tennis again, but quickly found to my own disgust that I am miles away from where I should be in Tennis. I thought I was a decent player from my childhood but got handed my @#$ on a silver platter by whoever I played with
• Accidentally found an extremely good and professional Tennis coach who started coaching me.  We started out infrequently a few times per month as our schedules permitted but I got totally hooked and we ended up with serious training almost daily.
• Probably as a result of the -for my shape insane- training regimen, I developed back, leg and shoulder problems.
• On a business trip in Japan, I came down with what seemed like a serious lower back problem, debilitating pain and immobility but was able to somewhat fix it with exercises and stretched my colleague showed me who had had the same issue earlier
• Back at home I saw an -I think very skilled- PT, specialized in sports. He evaluated me and came to the conclusion that I am in ok shape, have no fundamental issues and can take this kind of training if I want to, however, I absolutely should add other sports for balance. He strongly suggested running.
• I strangely started to enjoy running (I used to hate it), it was actually becoming a meditative thing quickly. I was running not very fast, but usually at least one hour about every second day. I purchased a pulse watch and took it quite seriously. Started to increase my pace and the running developed into an activity for its own sake, not just a balancing exercise for Tennis.  My favorite running area was by the waterline on the San Francisco Bay and I was starting to train for competitive runs, aiming for 10k and half marathons. Still, no great times, but definitely well within acceptable ranges for my age.
• In a running shop I took the advice of a sales guy who said I should try “minimal” running shoes as my gait is very normal and it would be good for me. However, he said I had to watch for my Achilles as lots of people get problems with it when changing running styles like that.
• The minimal running shoes were great, I was faster immediately and actually enjoyed running even more.  I started to develop some aches and pains in various parts of the legs but not the Achilles so I completely forgot about the note of caution of the (apparently very knowledgable sales guy, himself a very strong runner)
• Somebody - I think it was my PT, actually said I should not change running styles like that at my age (48) but I ignored that as it felt great
• In order to avoid injury I started some gymnastics, weights, stretching and all that but admittedly not very intensely
• In the year leading up to the ATR I have done more sports than ever in my life, a lot of running, a hell of a lot of Tennis and quite a lot of hiking in mountains. I did a sports evaluation (spiro-ergometry) which showed that I am ok but should do more low intensity endurance work. I followed that strongly by deliberately running slower at a much lower heart rate. There had been only few days in the entire year  with less than one hour of sports, e.g. when I had a cold or after falling when running during a business trip in LA
• Before Tennis practice I usually warmed up for an average of 10-15 minutes including stretching some light running
• When I went running, I started out very slowly and only gradually increased the pace. Sometimes even stopping in the beginning for stretching and in between when I felt aches and pains
• My job consists of a lot of traveling world wide, telephone and of course the computer, so basically not a lot of movement during work

Sum: Long term potential factors

• I often rest my feet on the wooden bar connecting my desk’s feet about 30cm above the ground. The situation is such that when I do that, the AT gets to rest on the bar. The bar is rectangular and only about one inch deep/wide so it bends the AT’s somewhat sharply. I always found that very relaxing but potentially it acts as a strain of the tendon which doesn’t seem like it feels/displays any pain
• The minimal running style and change from previous heal-strike style with strongly cushioned shoe
• Sudden, strong increase in activity in a short time frame
• A massage therapist had told me only about 1 week before the incident that my calves are very tense
• My left ankle suffered a torn ligament injury 30 years ago
• My left leg had another injury about 10 years ago when it was hit by a falling engine in a mechanic’s shop
• I had a muscle tear in my right thigh about 6 years ago which still causes some painful discomfort, potentially causing strange movements at times
• I learned after the ATR from histology of the torn tendon that “unspecific pre-existing damage” was visible on the tested pieces
• I found after the ATR when in my hospital bed that massaging my good AT, it was actually very sensitive or even hurting slightly, something I had never noticed before probably because I had never paid attention to the AT’s before
• My Dad had ATR also playing Tennis when he was a few years younger than I am now
• When I was a baby, there was a scare about babies dying in their sleep from choking when sleeping on their backs, so I was put on my belly.  I still basically can only sleep like that.   The feet are quite angled downwards when sleeping in that position. I started to “hang” the feet outside so they can be more at right angle many years ago and find it hard to sleep in beds (traveling) where I can’t do that. All this could have a direct impact on the AT’s I guess

The day of the ATR

• Business trip to completely different climate
• It had been a stressful day at work, I was running way late, stuck in traffic
• Cold day (around freezing)
• No time to warm up, came a few minutes late and just jumped into the game (didn’t happen until 40 minutes later, though)
• I had not done much running or other sports for a few days due to bad winter weather
• Different playing surface (carpet with sand) from what I am used to (concrete court)
• I don’t like doubles as there is very little activity/running most of the time, then very sudden, explosive moves
• I don’t like playing indoors, somehow I don’t feel get enough air, warm up properly
• Before the ATR, there had been a few rallies which had been very intense with a lot of explosive moves and running

While probably not a single item on my long list above is exactly and individually to blame for the ATR, I do believe that most of them probably contributed in one form or another, that’s why I listed all that. Interested to see comments.

January 23, 2014, 7pm in Germany, I am playing Tennis (doubles) indoors. About 40 minutes into the game, I am playing backhand side (left), returning a serve. My return is returned, a very easy, light, relaxed ball comes my way. I have to take about 2-3 easy, relaxed steps to get to the ball, more like getting/turning into the proper position for a backhand than to actually “get it”. One or two steps - bang.
I hear the characteristic “pop” and feel like having been hit with something (for example a Tennis ball) in the back of my left leg. Even though I have no pre-existing detailed experience or knowledge of this kind of injury, I somehow know in that same instant what has just happened. I let myself drop forward to the ground in order to avoid doing more damage (lack of knowledge here, no particular danger of doing additional damage) and while on my way down “making peace” with the thought that an active lifestyle would be slowed way down at least for a while. Strange, I am very clear and in less than a second, even before I hit the ground, have already become perfectly calm about this.
I am not normally very temperamental, but I can get very excited and upset about stuff. Two years ago, I injured my right big toe as I kicked a door in anger about software not working. Here, I completely understand that it is nobody’s fault, not even my own, no case of terrible injustice or anything like that.