Swelling (& elevating) is getting OLD!

Written on April 30, 2010 – 11:06 pm | by normofthenorth

Yup, that’s the message! After 20 wks, my ankle is remarkably back-to-normal in almost every way, except for calf strength, which isn’t back yet.

But after a day of “normal” standing and sitting and a bit of “normal” walking, my leg feels anything but normal, until it gets stuck up onto a table or at least a footstool! My foot and ankle are visibly “fat” then, too.

I’m ready for this to fade toward. . . normal!!

BTW, I take a daily “baby” aspirin (to help with a congenital heart-valve problem) and two SMS tablets, partly to help with this leg inflammation thing.

17 weeks, still improving (though slowly)

Written on April 10, 2010 – 12:16 am | by normofthenorth

After weeks of hanging out here several times a day, the death and re-birth of AchillesBlog.com gives me an unusual double-snapshot of a slow phase of recovery. It’s like seeing an old friend for the first time in a long while, when it’s easy to notice physical changes that might have been invisible if you’d stayed in touch.

On the other hand, most of my improvements are still evolutionary rather than revolutionary. My walking gait is now USUALLY normal or “perfect”, except for the first few steps of the day and the first few after I get up from sitting for a long time. I no longer have to grunt and strain to walk without that little “dip-limp”. On the other hand, I’m still too weak to do even one single-leg calf raise, much less a bunch.

Everything else — except strength and sports — is pretty much totally normal now. I’ve been wearing all my normal shoes, and moving around as I please, and sometimes even forgetting that I tore my AT 17 wks ago(!). I’m not especially nervous about tripping or being tripped any more. I’m even mounting and dismounting my bicycle without thinking much about where my foot is on the pedal, and ditto while walking down stairs — except that I’m treating both of them as calf exercise most of the time!!

Walking around the house and down stairs, I’m often doing the “native American dance”, starting high on the ball of my foot and trying to drop down slowly and in control. (No drums or singing, though!) That controlled “drop” is still a challenge. After I do enough of that kind of exercise, I sometimes have trouble walking perfectly, so the progress is still THAT gradual.

After my speedy progress through the first 8-10 weeks of my (non-surgical) protocol, I was clearly expecting my left leg to be stronger by now than it is (and I said so in my blogs, too!). But I’m still about a month ahead of my progress 8 years ago, after ATR surgery and in the care of a very conservative ortho-surgeon with an excessive fondness for casts.

The excitement now is that I’m about to head off to Whistler for a ski week! This trip has been scheduled for a long time, and it’s been one of my landmark goals from the start, and now it’s just a day or two away!! Yay!!

I’ve tried on the ski boots, and the left one fits fine on my still-slightly-oversize foot — frankly to my surprise, because my boots have always been quite tight, giving me black (bruised) toenails when I get jammed forward, and such. (I think I’ll be elevating my leg a few times a day.)

My physio noticed that my AT is “slimming down” much closer to the shape of the other one than it was a month ago, and I’m starting to regain those hollow “pockets” on either side of my heel. (They should have a name! Anybody?) And he measured my ROM while pushing hard, and he says it’s (a) indistinguishable from the other ankle, and (b) well within the range of “normal” and “fully functional”.

So it seems that this non-surgical cure has managed to do the one thing that seems most impossible, which — is to build an AT of the proper length out of one that had a sizable gap in it. Don’t ask me HOW a human body can do this by itself, because it still seems impossible. But the recent studies show that it usually happens just as successfully as with surgery, and my experience seems to show it, too.

He also tested a bunch of other kinds of ROM (besides plantarflexion and dorsiflexion), and he proclaimed my foot and ankle solid and stable and suitably mobile in all directions — just weak in the calf, and also not especially strong in the posterior tibial tendon, either.

Interestingly, I’ve always had some trouble with my right (”good” foot) arch collapsing when I ski (and probably other times, too), and Chris-the-PT thinks that’s all because the posterior tibial muscle-tendon pair is weak on my right foot, too. (Like chiropractors and Faith Healers, some Physios think they can heal everything that ails you!) I’m trying to exercise them both, though not with a Theraband, as Chris recommends. I’m mostly putting both feet up and pushing them against each other, imitating a Theraband.

Chris has decided that he can’t do much more for me with Physio, so he’s transferred me to a colleague for more exercise-like work. Dynamic Motor Therapy, or some similar phrase. That starts soon after my ski week ends. And in about 4 weeks (at 21 weeks), I’m scheduled for a series of “Bio-dex” tests, to quantify my strength and ROM etc.

I spent a week in Florida at the end of March, and I had a surprising amount of swelling in my “bad” leg and foot for several of those days. Probably just too much standing and walking and shopping and kite flying and sitting normally, and not enough elevation. When I finally noticed it, it was pretty ugly. So I started elevating a bunch (and also using an elastic sleeve brace and even icing some), and I was surprised how long it took the swelling to go away. I think an ounce of prevention is worth a pound of cure, as somebody once said.

So, wish me luck on the ski slopes next week! I’m not sure which part of my body will be most at risk, but I’m sure NO part of me will be totally safe, alas! (I have a knee and a shoulder that still occasionally remember ski “blow-ups” from past years!)

Eight years ago, my physio told me I was crazy to go skiing, though, and this time Chris thinks I’ll probably be fine — at least around the left ankle! I’m about 3 weeks earlier on the Achilles Marathon this time, but everything has been coming along much quicker this time, so I’m reasonably confident my ankle will be OK.

I hope everybody else has been healing well while we’ve been apart, and I hope our little “gang” will gather back here again, now that the site is up and running again! (Thanks, Dennis!)

More small steps at week 13.5

Written on March 15, 2010 – 11:06 pm | by normofthenorth

Physio last Friday and today, as my schedule and PT Chris’s would have it. He spent a lot of time digging HARD at a tender spot just below my “inside” (medial?) ankle bone. It hurt WAY worse than the rupture or most anything else connected to the ATR!

He says that spot is the attachment point for the OTHER tendon that can dorsiflex my foot. (Most of you know that somebody with a 100% torn AT can still point their toe and even push a gas pedal normally, but not climb stairs normally. The other muscle and tendon do a similar job to the calf-AT pair, but they’re much smaller and weaker.)

I’m guessing that I’ve been over-working that muscle-tendon pair a bit with all my concentric and eccentric heel-raise-type exercises. And last night, I was grunting and clenching my fists while walking fast, in a successful effort to eliminate the limp-dip at the end of my stride. Probably some of that was with this ancillary muscle-tendon pair, too.

That experiment at least FINALLY confirmed what I’ve been guessing — or wishfully thinking — for maybe 4 weeks already: that I’m really, REALLY close to having the strength to walk normally.

Today I bicycled to Physio again, up one of Toronto’s meanest hills. BOY, am I out of shape! My AT and calf were the LEAST of my worries, and part-way up the steepest part, I stopped and walked my bike the rest of the way! (That was AFTER shifting into my lowest “Granny gear”!!)

The good news was that the smaller hill, farther on, that almost wiped me out the last time, was a “piece of cake” this time. The other good news was that I actually arrived on time to Physio.

After PT, I ran several errands by bike. On my way home, cycling in traffic after dark, I had a novel and nifty experience: At one point, I suddenly REMEMBERED that I was nursing a torn-and-healing AT. Then I realized what that meant — I had FORGOTTEN all about it, for the very first time since December 8th! Now THAT was fun!

Good spirits and good healing, everybody!

P.S. If you have any comments specifically about surgery vs. non-op approaches, please post them in a comment on the previous page, which is now linked from the home page here — thanks, D!

A more complete review of the options — surgical vs. non-operative

Written on March 8, 2010 – 4:14 am | by normofthenorth

[Note: While this review, now 3 years old, is still a pretty good summary of the evidence on "op vs. non-op" and how it has changed since 2007, we've been having some more modern discussions, partly at my "The case for skipping ATR Surgery" page. And there are two new articles -- one a meta-study and one a journalistic summary of the "debate" -- that are especially worth reading: The meta-study is Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs. Non-surgical treatment of acute Achilles ruptures: a meta-analysis of randomized trials. Presented at annual meeting of the American Academy of Orthopaedic Surgeons, San Diego, February 2011.
And the journalistic summary is at http://lowerextremityreview.com/cover_story/battles-of-achilles-the-operative-vs-nonoperative-treatment-debate , entitled “BATTLES OF ACHILLES: The operative vs nonoperative treatment debate”. Following is my March 2010 summary of that debate. -Norm]

I just did a bit more online research of my “new fave” subject:
Is there any significant benefit to ATR surgery compared to the newer and quick-ish non-surgical protocols, like the one I’m following?

I keep hearing, even now, that serious athletes just HAVE to have the surgery if they’re serious about (a) avoiding re-rupture and (b) regaining their past (or achieving their best) strength and ROM. But the recent scientific studies I’ve looked at — one from NZ and one from Canada — both say (”prove”?) it ain’t so. But I keep hearing it, as if it is so.

Today, I looked harder to see what’s out there, and here’s what I found.

1) In the “old days” — including late 2001, when I tore my first ATR — there had been many studies that compared surgical vs. non-operative outcomes, and most of them concluded that at least some of the “athletic” outcomes (usually re-rupture rates) were better with surgery. That understanding was nicely summarized in a 2005 “meta-study” of all the earlier studies:
The Journal of Bone and Joint Surgery (American). 2005;87:2202-2210. Treatment of Acute Achilles Tendon Ruptures: A Meta-Analysis of Randomized, Controlled Trials, Riaz J.K. Khan et al: A 2005 meta-analysis of earlier studies, involving 800 patients and with “a variable level of methodological rigor and reporting of outcomes”. It found a 3-fold increase in re-rupture rates with non-operative care, and an 11-fold increase in other complications with surgery (both statistically significant). It also found that boots produced better outcomes than casts, and (slightly) that percutaneous surgery was better than open surgery.

2) Those studies may have randomized the two streams of patients, but they did NOT treat the two groups the same! Back then, the non-operative approach REALLY WAS “CONSERVATIVE”!! I.e., it was slower, and involved more immobilization and NWB than the post-op approach. And the evidence is very clear, especially now, that long immobilization and NWB (and no physio, etc.) are all BAD for outcomes.

3) The situation changed a LOT in 2007, with the publication of the study from New Zealand, which I think was the first to (a) use rapid rehab for everybody and (b) use the SAME rehab for everybody. So this study tested scientifically for the effects of the SURGERY, rather than mooshing the effect of the surgery into the same “soup” as the effect of the faster rehab protocol that usually went with surgery. That study is as follows:
Aukland, NZ, 2007: Bruce C. Twaddle, FRACS†,* and Peter Poon, FRACS, Am J Sports Med December 2007 vol. 35 no. 12 2033-2038, “Early Motion for Achilles Tendon Ruptures: Is Surgery Important?: A Randomized, Prospective Study”, http://ajs.sagepub.com/content/35/12/2033.abstract: (The number of patients randomized is not included in free Abstract.) “There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups.”

4) The next three studies, all from 2009, follow that same practice, thereby isolating the claimed (but maybe fictional) benefits of surgery from the ACTUAL benefits of rapid rehabilitation:
a) http://www.ncbi.nlm.nih.gov/pubmed/19825777?dopt=Abstract — Netherlands: Metz R, et al, Sept. 2009. 83 patients randomized into two streams. Excluding the patients (8 surgical and 9 non-surgical) with “major complications”, strength testing at 3 months and 6 months revealed only one statistically significant difference, in which the NON-surgical patients were stronger.
b) http://www.medscape.com/viewarticle/588904 — Canada: Kevin Willits, March 2009 paper at AAOS 2009: “Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery”. 145 patients randomized. No statistically significant difference in strength or ROM or re-rupture rate between the two groups, in two years of follow-up. Very significant difference — 2.6 x — in the rate of “complications”, with more in the surgical group, of course. “This is a great study and a landmark paper, and it’s a model of how to perform a randomized controlled trial,” commented Paul Fortin, MD, director of foot and ankle surgery at the William Beaumont Hospital, in Royal Oak, Michigan, who moderated the session at which the paper was presented. “The data are very clean and it’s potentially practice-changing.”
c) Gothenburg, Sweden, May 2009: http://www.physorg.com/news161516132.html — Katarina Nilsson Helander randomized 100 patients. The study found “no difference in the re-rupture rate. A year after the injury, there was no difference in the patients’ own impression of symptoms and function”.

5) ALL of those studies from 2007 on, find that there’s NO benefit from the surgery, as long as both groups get identical and rapid rehab. And both groups do just fine, in all those studies. (In one of the studies, the NON-surgical patients are stronger on one test at the final check, and that’s the only difference that’s statistically significant!) And I’ve included all the recent studies I can find!

6) So, as far as I can see, there really is no excuse for some otherwise intelligent person to claim that the evidence shows that surgery produces better results, or better results for athletes, . . . than the non-surgical approach. Than the approach that’s still sometimes called “conservative”, though it shouldn’t be! The non-surgical approach seems to work just fine, just as well as surgery but without the pain and complications. A really CONSERVATIVE approach, however, does NOT work fine, with or without surgery!

As “regular readers” already know, I’m following the protocol from 4b, above. And so far, so good — though (at 12.5 weeks) I’m getting tired of waiting for a good stride push-off, and then for a 1-legged heel raise. But so far, I’m very impressed with my progress on the non-surgical protocol — and I’ve also got experience with the surgical side, from 8 years ago. My life is back to normal except for the volleyball and stuff, and way quicker than I recovered the first time, post-op. It’s hard to complain.

If anybody’s got anything to add, like good studies I’ve missed, please respond here.

Finally, in my research, I also found a new surgical article from Japan that is a real eye-opener:
Novel Approach to Repair of Acute Achilles Tendon Rupture: Early Recovery Without Postoperative Fixation or Orthosis(!). Am J Sports Med February 2010 vol. 38 no. 2 287-292, Tadahiko Yotsumoto et al. The abstract’s at http://ajs.sagepub.com/content/38/2/287.abstract .

They only had a small group, but they applied a surgical “technique of their own design” to the whole group. Here’s more:
“The patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery.

Results: The range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous single-legged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. T2-weighted magnetic resonance signal intensity recovered to equal that of the intact portion of the same tendon at 12 weeks. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. The Achilles tendon rupture score averaged 98.3 at 24 weeks. There were no complications.”

These are truly spectacular results, by anybody’s standards! (Doug53, eat your heart out!) I mean, 20 continuous single-legged heel raises at an average 9.9 weeks post-op! That’s Very Good.

If I were making the choice today, anywhere near Shimane University School of Medicine (wherever Shimane is!?!), I think I might just go for the surgery — THIS surgery!

The good news for all the future American ATR sufferers, is that it’s probably easier to teach an old ortho-surgeon “dog” THIS kind of “new trick”, than it is to get him — yes, him! — to admit that it’s better to skip the surgery altogether.

Small victories, still waiting for calf strength

Written on March 1, 2010 – 3:45 pm | by normofthenorth

Just past 11 weeks after “the boot” arrived, my left ankle keeps feeling better and doing better, and my lifestyle has returned to normal in almost every way except sports — but I still have a little “dip” in my stride, because my left calf still can’t “push off” enough to lift my weight. Now, it feels as if my AT can do it, but I still can’t.

Doug53 calls this the “frustrating plateau”, and it has been a little frustrating, because my progress up to ~3 wks ago was so strong and steady and fast, that I was ready to bet that I’d be doing 1-legged heel raises by around now. But no.

Meanwhile, the seat is gone from the shower stall, the kneeling footstool is gone from in front of the bathroom sink, the stack of clean clothes is back in the closet instead of beside the bed, and I’m just about to stop taking my backpack everywhere I go in the house, because I’m comfy walking around with my hands full, even on stairs (sort of).

Traveling around, by foot, by car, and by subway, are back to normal. I’m a year-round urban bicyclist, though, and I’ve avoided that for the last week or so because we’ve had snow and slush and some frozen slush and the like. I’ve biked a few times, but always in my hinged boot so far. Now it’s been so long since I’ve put the boot on, it would feel weird to wear it just for protection when I bike. I suspect my next bike trip will be in snow boots or low Merril-type “$hit-kickers”, and it will probably be in a few days, depending on the weather. I’ll try not to crash my weight onto my left foot too hard, especially while rolling forward — that’s probably about the only way I can still hurt my AT and ankle badly.

Standing on one foot (the “bad” foot) is remarkably solid, and I almost never get any abnormal “signals” (pain, discomfort, tingles) from my ankle any more. The only exception is when I stretch the AT hard, like doing 2-leg heel raises while hanging over a stairwell step. The ROM limit on that ankle still feels a little different than the other ankle, but that difference has faded enormously and is almost gone. What’s left is more like stiffness than pain or weirdness.

There’s an amusing postscript to my previous post: It was about a dumb “faux pas” I did about a week and a half ago. I was walking fast, outdoors, in shoes, and I got frustrated with the “dip”, so I tried “dipping” the rest of my stride to match. Dumb idea! I ended up dorsiflexing and loading my ankle-and-AT way too much, and I almost crashed, with a pretty sharp pain.

Well, last night, walking home from about a block away, I tried it again, carefully. I got crouched down enough, while walking, that I could walk perfectly straight! Of course, it’s just a slightly different “silly walk”, but (a) it’s interesting that I can keep my eyes at a constant height while walking, as long as it’s a bit lower than normal, and (b) it’s interesting that the same move that hurt like crazy about 10 days ago is now comfy.

It’s all good, all in the right direction, and all much faster than last time (and without surgery! Miraculous!!). But I’d really like to be able to “push off” and walk straight at full height!

Doug53 took about 3 weeks for the transition from limping to walking straight. My physio guessed that it’d be a month. I was guessing a week or two, but I think my guess has already expired.

I’ve been trying to calibrate my progress by pushing down on a bathroom scale, but I think I’ve been too inconsistent in how I’ve been pushing to get good info that way, until quite recently. Now I’ve started consistently doing it “the hard way”, with the scale behind my body, and the ball of my foot pushing down on the middle of the scale, just like a walking “push off”. 100 pounds is still a stretch, and I need more to get to a straight stride, not to mention a 1-leg heel raise. But it’s enough that my 2-leg heel raises are now normal (though I’m mostly doing them on a stair step, so I can include some dorsiflexion).

The ROM on my “bad” (left) ankle seems to be matching my right ankle exactly, which is totally weird! My right ankle LOST a bit of dorsiflexion from my ATR surgery 8 years ago. (My surgeon said he tried to err in that direction rather than make the AT too long.) But my left AT had a big gap in it, and the ends were never drawn together surgically, they just “healed up”, presumably with new connective tissue “filling in the gap”. If it healed at the original length, it would seem like a miracle, but a smidge shorter?!? This whole non-surgical cure is way magical. . .

Good healing, everybody!