The gradual approach

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!

8 Responses to “The gradual approach”

  1. Generally very smart and sensible. A couple of notes
    - The AT doesn’t become a healed and strong AT by tons of healing followed by “a little bit of stretching and flexing”. I’ve read that there are maybe three different materials (forms of collagen?) involved, succeeding each other. (Think gelatine then glue then rope.) And it’s exercise or motion that prompts the changes.
    - Listening to your body and avoiding pain is necessary but not sufficient. Pain from reinjury can set in hours after overdoing.
    - ” Very aggressive on one side, very conservative on the other” indeed! Makes me wonder if he knows more or less than the folks at UWO & Exeter and NZ. The key for me is tabulated results. If he’s got them and they’re superior, then hang on his every word. If not, and he’s following his nose, a pet theory, an experiment he’s always wanted to try… then Not So Much!

  2. Norm, completely agree. Have been following my own nose, gut feel and PT recommendations. Now walking in boot a lot and doing as much exercise out of the boot as I can. PT says foot is developing very well, good range of motion and starting to develop some strength. I found transition to FWB easier said then done, PT helped a lot.

    I developed a MAJOR back pain (nothing serious, just muscle spasms from unevenness, hugely painful and debilitating, thus major nuisance and set back for daily activity)
    Working on that more than on the foot these days.

  3. And here I’ve been thinking that the miserable backache that’s been plaguing me for the past few days was for NOTHING! NO! It’s in sympathy with you! :-)
    Good luck to BOTH of us! And don’t put too much stock in flattery or “puffery” from your health professionals.

  4. Norm, hope that back is getting better - if it’s out of sympathy with mine, then it should as mine is getting better after losing the boot!

  5. I actually saw a GP about my back (and assorted other ills) today. She prescribed a muscle relaxant that’s made me drowsy. My back had a pretty good day (before and after the pill) — not normal by a long shot, but better than yesterday. May the trend continue!

  6. Yes, may the trend continue! For me the only thing helping is evenness and exercises and not sitting in a car for hours per day…

  7. The car is the WORST! Not sure why.

  8. Yes, include the insanity of Silicon Valley traffic (not to claim it’s any worse than anywhere else…) and it’s “Hell on wheels”.
    Looking forward to jumping back on the motorcycle instead. I think I could technically handle it already, just not sure about the risk of having to urgently put a foot down. I did easily 50000 miles over the last few years, just never with an injured foot.

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