Maybe healing a bit short is scary after all!
Written on April 30, 2012 – 9:22 pm | by normofthenorth
I saw a nifty podiatrist/chiropodist today, here in Toronto. (The two names are interchangeable here, though apparently not elsewhere.) My immediate problem was a nasty corn on top of a “hammertoe” that got very upset on my first ski week in Whistler, back in Jan-Feb. The bad toe was on my RIGHT foot, the one I’ve been calling my “good” one, though I did an ATR on that side in late 2001, and had it repaired surgically.
He examined my feet and legs and analyzed my gait very carefully, and told me I had CLAWtoes, not hammertoes. On both feet, too, though the causes were different. On the left, I’m compensating for a deficit in strength and stability, left over from my ATR. But it was my right ankle that worried him the most!
He says that I’ve been over-compensating for a deficit in dorsiflexion ROM, left over from my ATR surgery. When I mentioned it to my surgeon ~10 years ago, he said he did it on purpose, because “healing long” creates a functional deficit and healing short doesn’t. And I’ve basically agreed with him ever since. But no!!
This Doc said that my basic DF ROM was less than 15 degrees, which is the standard minimum a person needs to stride normally. (I.e., when you walk over your planted foot, that foot has to flex to 15 degs of DF to stay on the floor while your weight shifts to the other foot.) I don’t have that on my right (10 year post-op) ankle, so there are a few ways to “make do”:
(1) I could splay my toes out to the side. (I may do that when crouching on the volleyball court, but I don’t do that when walking.)
(2) I could hyper-extend my knee(s). (I did that as a kid, but he doesn’t think I’m doing it now while walking.)
(3) I could lift my heel earlier in my stride than “normal”. (I DO do that.) And
(4) I could open or dislocate the joint on the top of my foot, medial side, in front of my leg, which collapses my arch and gains me some DF ROM. (I DO do that, too.)
That joint involves the “halus” (bone? joint?), apparently. And he says that continuing to open or dislocate that joint while it’s got my FW (180-ish pounds) on it will eventually destroy the joint, and it will collapse.
He prescribed a few solutions:
(1) I can try some stretching, being careful to keep that joint closed while I’m doing it. One way is to push my thumb into the joint (where he did), but that’s hard while doing a WB stretch. The other is just to make sure that my knee and center-of-gravity are “inside”, almost in line with my big toe, when I stretch. He admitted that it was a long shot that stretching would gain me much AT-and-calf length 10 years after the surgery, but he thought it was worth trying for a few weeks.
(2) He customized two of my standard footbeds (new-issue from a pair of shoes — Skecher Shape-Ups — that I’d worn there), adding (a) a 1cm heel lift to decrease the DF I need to stride properly, and (b) a ~0.5cm meditarsal support (which he custom-made out of peel-and-stick fiber stuff) that holds up the balls of my feet under the base of all my toes except my big toes. That will let me load up the front of my foot WITHOUT doing the “claw toe” thing. (In my case, when I do “claw toe”, the big joints on my toe flex, knuckle up, banging on the top of my shoe or ski boot, and the smallest (philange?) joints hyper-extends. So each toe does a sideways “Z” when they’re pushing hard, but the meditarsal support discourages that.
He wants me to wear that customized footbed (and try the stretches) for 6 weeks then see him again to see if anything has changed.
Meanwhile, my right knee has been bothering me — mostly when I walk stairs, esp. down — and the sports-med Doc who’s been examining that has suggested that I consider custom footbeds in case the kneecap (patella) is out of place, so maybe this will help. (It already feels better than it did, but it does come and go; we’ll see.)
I was very surprised how concerned this foot-and-ankle-and-gait expert was about my “good” post-op leg — the one that CAN do a bunch of full-height 1-leg heel raises! — and how OK he was with my “bad” non-op leg — the one that has a clear strength deficit, though one that doesn’t seem to affect my running or jumping or bicycling or volleyball playing. And it made me re-think some of my oft-expressed (here) bias against early dorsiflexion stretching. I’ve been quite content with my reduced DF ROM on my post-op side. But I didn’t realize how reduced it was (because dislocating that foot joint fooled me, but not this Doc), and I certainly didn’t realize that doing what I’m doing is threatening the longer-term viability of that foot! (I’d been wondering if getting older and weaker would make me start limping on my other, post-non-op foot when I didn’t have enough calf strength to stride properly, but he made it sound like I’d lose the use of my other, post-op foot, sooner.
There’s today’s lesson from me, FWIW. Maybe the best audience for the message is Orthopedic Surgeons like my first one, who are tempted to trim ruptured ATs short, because it doesn’t do any harm. . . (Too bad they don’t read AchillesBlog.com!!)
Tags: healing short, ROM, stretching, surgery
20 Responses to “Maybe healing a bit short is scary after all!”
By ultrarunning316 on May 1, 2012 | Reply
My doc was way more concerned with me healing short as an ultra marathon running doc the first thing he said to me was we don’t want that…The only time he had me wearing heel lifts was in the very beginning & when wearing the cam boot at work but only the one lift. He was very concerned about my gait. I’m happy to see that he was correct as this sight and some of your earlier comments had me questioning his decisions…I know you didn’t make those earlier comments out of anything but concern for others, especially after reading about a few that did heal long…Thanks for this post Norm!
By ryanb on May 1, 2012 | Reply
Good luck Norm. I don’t think there’s much hope of stretching your tendon. However, the muscle should be workable- with a disciplined stretching regimen you should be able to gain a significant improvement in the range of motion. If you’re still weightlifting, I’d always be focusing on as full of a range of motion as possible too; with good stretching before and after.
In some ways, your description of the foot beds sounds similar to the ones I wear every day: http://www.aline.com
I still think healing long is the bigger risk; because, as I state above, I think that with hard work the calf muscle can be stretched to compensate for a short tendon. Too long, and you’re just SOL.
By normofthenorth on May 1, 2012 | Reply
Thanks, both. The worst thing about changing one’s mind — or even slightly tempering a strongly-held view, as I have — is that you didn’t have the “whole truth” earlier. (Good thing I’ve got it now, right?
)
Ryan, it still may well be asymmetrical, as you suggest. Certainly a bit short gives fine early strength, and the cons can be accommodated. But if that accommodation has a high long-term cost…
Also, if you’d told me 2 years ago that the non-op cure would leave me grunting to get a few half-height 1-leg heel raises, I might have taken a scalpel to my own ATR! Yet I’m pleasantly surprised — shocked, even — that my strength deficit has made no noticeable difference in my sports performance, even in volleyball!!
BTW, I’ve never been into weight-lifting, except briefly for rehab — ATR, cardio, golfer’s elbow, etc.
By starshep on May 1, 2012 | Reply
I’m non-op and started my PT 3 weeks ago 7 weeks after my ATR. They had me doing DF ROM right from the start. I was a bit leery about it but I did what they told me to. Every time I’d do a DF I was cringing wondering if I would hear the “pop” but fortunately never did. About a week ago they measured my DF and it was at 15 degrees and seems to be holding at about that. Glad I trusted the therapists.
By normofthenorth on May 1, 2012 | Reply
It’d be good to see some stats, Starshep, but I’d be surprised if “healing short” is a problem for non-op patients, even without early stretching. (I’ve got lots of flexibility on my non-op side, it’s only my surgically repaired side that’s short, and has been since the repair was done.)
I guess it’s conceivable that an AT whose ends were jammed together too tightly (e.g. with too many heel wedges) could heal shorter than before, maybe, but I’ve certainly never heard mention of it.
In ~2008, some of the UWO-study folks published an analysis of the possible relationship between non-op clinical results and either initial ATR gap size or location, analyzing only those patients from the UWO study who had good initial gap measurements done with Ultrasound. They found no significant relationship of either to clinical results. I THINK they would have mentioned if patients with larger initial gaps generally healed longer than those with smaller ones, but they didn’t, as I recall. (All the UWO patients got 2cm of heel wedges.)
I think they only had ~25 patients in the entire sample (about 1/3 of all their non-op patients), so there may have been a reasonably strong-looking correlation that still wasn’t statistically significant in that small a sample.
By normofthenorth on Jun 7, 2012 | Reply
I was supposed to return to Dr. Ng next week, but his office phoned to re-schedule, and offered this afternoon, which I took. He decided that the heel wedges he’d given me (and which flattened out pretty far in the first few days) hadn’t accomplished anything in changing my gait (esp. on the right-hand “repaired short” side), so we’ll forget heel lifts going forward.
But the pads he gave me under my metatarsals, intended to straighten my toes esp. my right-foot #2 “claw toe”, were probably helping and should be continued. He’s an engaging and engaged and quick-witted guy, and he’s obviously fascinated by my situation, though he doesn’t really see a way to cure it.
My right ankle is a bit too rigid and ROM/DF-limited since its ATR surgery, and I’m still compensating partly by lifting my heel early in my stride — something I think I partly learned while doing calf-strengthening “silly walk” exercises after both ATRs! My left ankle is a bit loose and over-flexible (though NOT in the DF direction!) since healing non-op, and he thinks I’m compensating partly with an early heel lift and partly by pointing my toes a bit to the outside. (Really?)
When I suggested that my early heel raise while striding was at least partly “learned behavior” from rebuilding atrophied calf muscles after my ATRs, he seemed doubtful. But you should find several hits here on the phrase “silly walk” from a number of us who have altered our gait during recovery (and/or bought Skecher shoes or Vibram 5-Fingers) to work our calves a little harder when walking, and those habits die hard. Heck, I was so pleased and relieved when I first COULD lift my heel aggressively at the end of a stride, that it was very satisfying to do so, and I’m sure I’m not alone in that.
I also told him that during 3 hours of non-stop competitive 4-on-4 beach volleyball last Saturday night(!), I could feel some slight discomfort along the outside (left side) of my left ankle. He said that made sense: Virtually all lower legs have an imbalance of muscle strength between the inner (medial?) and the outer sides, with the inner muscles much stronger. My extra left ankle mobility (including overuse of the talus joint on that side, too) somehow exacerbates that imbalance, over-working the muscles down the outside of my shin when I run and jump, maybe esp. on the sand. (I forget the details, but he said that striding and jumping usually entails some “move” that mediates the strength imbalance, but my left ankle isn’t good at that move because it’s so mobile, maybe esp. at rotating toes out?)
He kept expressing fascination at how different my two lower legs were in their capabilities, yet how successfully I’ve adapted to regain high function. He sounded less ominous this time about the possibility of my talus joint eventually failing, though he did suggest that I continue stretching my right AT/calf (with the talus joint closed) to maximize my “proper” dorsiflexion.
I left with TWO sets of Dr.-Ng-modified footbeds (and enough peel-and-stick felt to make several replacement metatarsal supports), so I don’t have to constantly switch one set between my indoor Crocs and my outdoor shoes every time I go in or out.
On the one hand, what he’s found seems real and potentially important. He also suggested how I should, and should not, modify my right ski-boot footbed to help me edge my right inside ski edge without collapsing my right arch. OTOH, if I hadn’t inherited funny long toes that over-extend at the first joint (”claw”) and hyper-extend at the last joint (”weird” except in my family!) — none of which has ANYTHING to do with either of my two ATRs — or if that condition hadn’t led to a nasty fight between one of my toes and my ski boot during a ski week in Whistler, I never would have gone to a podiatrist, and the rest of my “condition” would have remained undiagnosed.
As it is, I’ve had my gait carefully examined by an expert, who’s shed some light on the imperfections I’ve got on both sides, largely the result of my two ATRs and the way they’ve healed. (Now I’m left with the suspicion that if I went to an arm expert and showed him how I row or paddle or throw a ball, he’d find similar undiagnosed problems with my arms — and likewise with any other part of my body!
)
All that said, lifting the balls of my feet with a metatarsal support pad does clearly straighten my toes, so that’s a Good Thing. And stretching my “healed short” right AT whenever I think of it probably can’t do any harm. The rest probably “is what it is”. . .
By philip on Jun 28, 2012 | Reply
Hi Norm, I have a question for you. I see by your historical posts that you had ultrasounds during your PRP injections. It looked like each showed varied results in terms of gap and type of tear. Do you recall the different stages of gap width? I am at 6 weeks and today was told that I have a gap of 1cm. I thought it might have been a rerupture but the doc doesn’t think so given the gap is apparently surrounded by tissue - either scar tissue or tendon. It seems interpretation is more art than science? Thoughts?
By normofthenorth on Jun 29, 2012 | Reply
Ultrasounds are definitely more art than science, Philip. And I think MRIs are no better.
My three Ultrasounds were at 1-week intervals, starting maybe the day I was immobilized, a few days post-ATR. (I forget how many, but my blog probably remembers!) He (the same, illustrious Doc) said the first one looked like a complete ATR, the second one looked more like a partial tear, and the third one looke like multiple partial tears.
You can interpret them as “different stages of gap” if you like. I think it’s just as likely that the gap hadn’t changed much in 2 weeks, and the images were made from slightly different positions and/or at slightly different angles. E.g., I may have had a second AT tear, farther up, all along, but the first two U-S shots didn’t extend far enough up my leg to show it.
Some patients get a (gentle) Thompson test at 6 weeks. Many of them are encouraging, though not all — even among those that are on the path to full on-time recovery. If yours made your foot jump, you’d know you didn’t really have a 1cm gap. . .
By normofthenorth on Oct 24, 2012 | Reply
And again, an achillesblog.com outage starts soon after a post by Norm! (Of course, given the frequency of posts by Norm, maybe that’s no more than what’s randomly expected. . .)
By justinsmith8199 on Jan 24, 2013 | Reply
Hey Norm,
Quick question. I’ve also torn both Achilles. Both have been surgically repaired. The latest one was torn almost a year ago in February. I probably have about 70% strength back (20 heal lifts until I need a break). I’ve been playing basketball and jogging. Still not ready to sprint yet. But I’m close.
My question is, is it safe to assume that with continued rehab: stretching, calf raises and using a wooden wobble/balance board, there is no reason to think I can’t get back to 95%-100% to where I used to be.
Thanks in advance for your opinion. It’s rare finding people who have torn both..What luck we have..
Justin
By normofthenorth on Jan 24, 2013 | Reply
Tearing the other AT later is unfortunately NOT that rare, and we’ve had a steady sprinkling of people wandering through here who’ve done it. What’s rare is tearing both at once, and we just got somebody here who did that — maybe the rhird I’ve noticed in the ~3 years I’ve been an addict here.
I’m not sure anything is “safe to assume” in ATR rehab, Justin. It’s safe to assume that if you keep working at it, it will turn out as strong and capable and fit as is reasonably possible. Whether that’s 85% or 105% or whatever is impossible to predict. We’ve got some statistics, but none of us is a statistic, and the median is not the message, etc., etc. Do your best and you’ll end up as well off as can be. That’s all we’re guaranteed, so make it all you need!
By normofthenorth on Feb 3, 2013 | Reply
Just a quick update on my sports activities on the two recovered ATs: Just back home from a ski week in Whistler. 6 days on the snow, a total of 120,000 feet of vertical, lots of them “slow feet” on ungroomed off-piste deep-and-steep runs, especially under the Harmony Chair (for those who know Whistler Mountain).
Can’t say I didn’t worry about my legs — just that I didn’t worry about my ATs!! My right knee has been slowly deteriorating for years of skiing and volleyball etc., but minds walking downstairs WAY more than it minds doing sports! And both my thighs were burning all week — maybe it was a mistake to do ~20,000′ of vertical on day one, including some off-piste (starting with my first “warm-up” run of the season!). Good fun, though.
Also, somebody was asking how long it took our ATR feet to return to normal size. When I skied at Whistler at Week 17 post-non-op (3 years ago), I had to use a very thin ski sock on that (left) foot, because my foot was bigger than it used to be. Since then, I’ve just used those very thin ski socks, so I didn’t know if the foot was still over-sized or not. This trip, I also brought a pair of regular-weight socks (wool hiking-boot socks), and I skied a day in them, no problem. My OTHER boot was getting a bit sloppy (on the foot that had an ATR ~11 years ago), so I ended up saving the regular-weight socks for that (right) side — since I only took one pair of them to Whistler!
So after 3 years post-non-op-ATR, my left foot seems to fit in the same boot and sock that it used to fit in, pre-ATR. And maybe it did a year or more ago, too, but I don’t know that.
Don’t read too much into my right boot being sloppy, since that boot usually needed re-tightening during the ski day all along, even before my first ATR. My feet aren’t perfectly symmetrical, and my boots aren’t, either! (And yes, they’re much more than 11 years old — old Raichle Flexons, and I still love them!
By kkirk on Feb 3, 2013 | Reply
Sounds great Norm, my lady was trying to get me skiing to this weekend, but we decided in a hike instead pushed 600 ft. Up and 6 miles, which is the most I’ve done yet! So, I know it’s a good feeling to get your life “all the way” back. Still a little sore and stiff today though
By normofthenorth on Feb 27, 2013 | Reply
I just posted on kimjax’s new page with my latest thoughts about my short right AT maybe causing or exacerbating my “trick” right knee. I wanted to post the link here, but I couldn’t find it fast with the iPod… Actually, it may have vanished yesterday, somewhere between my laptop and this site. (It was down for a little while yesterday, at least for me.) Maybe I can dig it up from my clipboard manager…
By nivergvup on Mar 1, 2013 | Reply
Was so happy to see that you are still on this site helping people. I am happy to report that I have been back playing court vball with no issues at all, although my vertical has suffered, though I am not sure if this is a result of the injury or age! Take care and keep helping.
By normofthenorth on Mar 29, 2013 | Reply
I just tried MANY times to post a version of this on alton2uk’s page, but ALL of them are “awaiting moderation”, for reasons I don’t understand. So here it is:
A year or two ago, doug53 blogged about his ultra-fast post-op protocol that included vibrator massage. He also briefly discussed some evidence that it speeds healing (maybe in rats?). It’s all here, just go to achillesblog.com/doug53 and find/read it.
(At least if it’s “awaiting moderation” HERE, I know who the Moderator is!
)
By normofthenorth on Apr 16, 2013 | Reply
More update now on that right knee — and maybe the short right AT, too!!
We’re finishing our second Whistler week now, slightly delayed and 3 days extended. I’ve fallen a bit short of my 20,000′/day (vertical) target this trip, partly because “sleeping in” feels so good, partly because I spend some morning time doing things like this instead of hustling to the gondola, partly because I like skiing Whistler’s Alpine steeps and deeps, which I ski slowly, and partly because I’ve been spending a lot of time skiing Whistler Mountain’s Glacier Bowl, which is only accessible from a long flat “cat-track”, and which also contains some long flat portions between the steep drops.
This trip, it’s been bothering me, and I’ve been working hard to keep it mobile and relatively pain-free — choosing a seat on chair lifts where I can swing my right foot/ski frequently, and stopping near the start of each run to do a bunch of knee, calf, and groin stretches. It’s still bothered me, maybe especially when I want to lift my skis up off the snow — either to start a deep-snow turn or to ski and turn over a bump (”avalement” to the ski-instructor crowd). Yesterday, that knee chased me out of Glacier Bowl down to the beautifully carve-able Upper Dave Murray & Tokum, which I skied repeatedly VERY fast, which helped INcrease my vertical. Still a bit short of 20,000′ — more like 19,000′ — but considering I didn’t start downhill ’til 2:00 and the lifts close at 4:00…
Well, the good news is that a LONG night of sleep has cured it at least 95%, yay! 
I’ll check my heel-binding settings, and if they’re at DIN 6.5, I’ll crank ‘em down to 6 in honor of my 68th birthday! 
i’ve still been hurt worse by unneccesary binding releases than by failures to release, but 6 is probably a reasonable compromise. (& BTW, I completely forgot to try to radio the DW after I blew up!)
That seems like a lot of “partly” reasons, but there’s 1 more: that “trick” right knee of mine, which may or may not be a side-effect of my repaired-short right ATR. Last ski trip, Whistler in late Jan, my first day of skiing seemed to “cure” that knee for the week, and I was ASSuming that would happen again this time, but no.
I also lost some time on a stupid, dramatic, painful, and SCARY “yard-sale” of a fall. I’d been trying to reach the DW on the GMRS walkie-talkie, mostly on chair lifts, while skiing fast with our Level 3 Instructor pal who’s staying in our timeshare with us. Just as I was flying toward the ridge between UDM and Tokum — a ridge the hotshot kids use as a jump, but I work hard to “suck up” so I DON’T catch any “air”! — I heard my radio chirp, the DW was calling. That ridge is a good place for radio reception, so I jammed on the brakes hard in the groomed-but-soft-and-corny snow just before the ridge — and I totally lost it! I guess my ski tips dug in, because both heel bindings released, and I tumbled to a stop on the far side of the ridge, leaving both skis behind.
That slope was slick and corn-free, and I fought hard to put the skis back on. When I did, and skied the last 1.5 runs of the day, and walking ~100 paces from the gondola base to the condo, I noticed a pain at the back of my right heel, near the AT insertion point. It felt exactly like the pain during my 1-month setback in my post-op ATR#1 rehab, after my dumb PT convinced dumb me to do as many 1-leg heel raises as I could. In the condo it felt worse, and walking to dinner after icing and showering, I was limping a little. Also limping on the walk home, then iced again in bed. NOT pleased to think that a heel safety-binding release can STILL hurt that repaired-too-short AT more than a decade post-op(!), and definitely not pleased to remeber that it took a full MONTH for the pain to go away the last (= first) time!
Also BTW, one of the reasons I started so late yesterday is that I was busy phoning medical clinics in Toronto to try to see my fave sports-med expert about my knee, the head of UofT’s sports-med clinic. I’m seeing my GP Thursday AM so she can send a fresh referral so I can see the Guru in June(!). I may go back to the other guy — the Doc who heaped praise on my knee a year ago based on X-Rays and MRIs — so the Guru will be a second opinion.
I sure hope SOMEBODY can fix that knee, because it’s close to ending my volleyball career, and starting to mess with skiing too.
By andrew1971 on Apr 16, 2013 | Reply
Good sleep is always welcome for me Norm, enjoyed reading our post a lot - I am not a skier so please forgive the lack of correct terminology - seems you still managed to ski pretty much to your goals.
Good luck with your knee, with all the continual advancements in understanding the knee I am hopeful of you getting the right result.
By ripraproar on Apr 16, 2013 | Reply
Phew norm.
You scared me for a while,good luck with the knee
By normofthenorth on Apr 18, 2013 | Reply
Thanks, folks! Walking to the Whistler gondola in my ski boots I felt “that spot” pulling a bit. Again, I expected a ski boot to be so close to an orthotic boot that it would protect everything, but no. I forgot to tune down my heel release, skied a pretty fast aggressive day on it and didn’t think about it again. Haven’t thought about it since, either, so I think it’s gone, at least for now. Made a digital note to adjust that binding release before next ski season.
This morning, still groggy from getting in very late last night, I bicycled to my GP’s to get a referall for my knee to my “guru” at UofT. She sensibly suggested that we have last year’s sports-med doc send my lab results to my “guru” — and to my GP, too. So I signed a release for that, which was sent to last year’s sports-med clinic. The UofT guru is booking for JUNE now, so there’s no big rush!
I’d been thinking of returning to last year’s guy as another opinion — I don’t think his lab-results approach is likely to work with my misaligned knee, but maybe it’s deteriorated enough that the diagnostic machines can find some deterioration that will steer us in the right direction. . . Now I’m thinking I may just wait.
Because I think it’s all mostly about alignment, I’m wondering about seeing a recommended chiropractor, too. We’ll see. Lots of other things to do. . .
Again, it’s worth repeating that my more recent ATR, treated non-op, was one of my few body parts that did NOT complain during my 9-day skiing marathon!