Nov 08 2013
Guess I’m in the “elongated” Club: 22 months post ATR
Haven’t posted anything here in well over a year. Felt like I was on the road to full recovery: mountain biking over 40 miles, alot of back-country skiing/hiking, stand-up paddling, surfing, and working with not too much discomfort - though never got the one-foot calf raise dialed. Then, about 6 months ago, things seemed to start getting worse, most notably on long walks or hikes. More recently all walking is uncomfortable and running is painful - and my calf has never developed on the medial side. I decided to go back to PT and see what was up… no calf and very difficult to make it fire at all - he was as baffled as I was.
I decided to do some research on this site and found a couple of stories of healing with an elongated achilles (notably "tomtom"’s story). This sounds like me: My calf hasn’t come back at all, but I don’t feel like I have and real difference in ankle ROM from the good side… I’m also getting pain and soreness on the lateral side just below the knee - this, I think, is because the smaller muscles there are doing all the work.
For now, back on a regimented and (hopefully) correctly-directed program to see if I can get the calf to wake up & at least make that part of the leg sore… because walking, jogging, biking, surfing SUP, and snowboarding are not doing it… I cannot fathom going under the knife again… don’t even want to visit an ortho surgeon - but that seems to be next on the list. I’ll post more once i get either results or more information.
PM: (1) I used to believe that “healing long” was always accompanied by above-normal DF ROM. It often is, but now I doubt that it always is, because I think there are a number of other “stops” in the ankle that limit our flexion, even in the absence of an intact AT (or an elongated one).
(2) Most of us who think we healed long have experienced weakness and a “plateau”, and only a small % have deteriorated or experienced pain. But exercising through abnormal weakness of one system can over-tax other neighbouring systems (muscles-and-tendons) that are recruited to carry the load, so it’s quite possible.
Good luck with the program. I have some weakness myself from ATR #2, but mine only surfaces when I do (wimpy) 1-leg heel raises. I’m otherwise happy with it, not considering a repair by a long shot. But others with more serious deficits have gone for a re-do (or a first-do).
I’ll know more in a year or so (after some more PT school), but I’m guessing that quite often there is not an elongation problem. The problem is mostly a strength deficit in the gastrocnemius. Why does the soleus heal better? I don’t know. Seems the gastroc is always fading away. Why do I think it’s not the soleus? It’s a long story and I’ll post more when I know more. That’s just what I got out of a professor of mine that teaches orthopedics.
Sometimes it is elongation. You could have elongation if something else is limiting your ROM, like the joint capsule and making your DF look smaller. However, I doubt it. I’m guessing the gastroc is just weak. Build it up. Anything straight legged.
Thanks for the input Norm & Mike & any other insights are welcome…
Norm, yes, I think most of the pain i am getting is from over-taxing the other/compensating systems.
Mike, you are correct, the gastroc is the very weak, and the soleus is taking most ofl the effort - this from a conversation with my PT. I can make the gastroc fire (weakly) when concentrating and doing non / partial weight bearing exercises… so it does work - the nervous system is intact. It just isn’t working during normal walking, biking & other activities.
Another reason I feel like it the AT may be elongated is that I can’t really feel a calf stretch on the repaired side anywhere near where I feel it on the good side.
For now going for 6-8 weeks of going back to almost square one with directed exercise with elastic resistance and calf raises on stairs - just going from flexed(heel below my toes) to neutral. Just trying to see if I can get some feeling in that medial side. Another surgery is an extreme last resort for me… I’m 42 and I’d really like to be able to run again, or at least hike for longer than an hour or so.
Will keep you posted on progress.
My PT, who’s kind of a character, scoffed of the whole idea of healing long. He said that, back in the days when he studied PT, the femoral shortening surgery was in fashion, and, it seemed, that all the muscles, tendons, and all other parts of the system miraculously readjusted to the suddenly shorter femur bone. Hence, ‘healing long’ in his opinion, is physiologically impossible.
Rather than healing long, he offered a few other explanations:
1. Excessive stretching of a muscle with low toning. This will damage the muscle, and can be very hard to repair. Of course, you may very well tro to do stretches on your AT, but be careful not to stretch in such a way as it feels like you are stretching your calf muscle. Killing the muscle is not a good idea.
2. Blocking in your ankle. Your ROM may be OK, but you may need excess power to get over that ‘threshold’. Because the ROM is not fully, but partly, blocked, which creates friction.
3. The ankle joint may be slightly out of position. The ankle has a plethora of small bones that I can not remember or imagine, however, if one or two of these are only slightly out of position, or if the small ligaments that keep them in place are damaged, weakened, or out of position, this will impact the amount of strength you will be able to mobilize in the movement.
From what I read, which is completely unqualified, I guess that something in your ankle is slightly our of position, inhibiting the function of your gastrocnemius.
In general, I believe the problems of ‘healing long’ are similar to the problems I have experienced after fracturing my wrist. 11 years ago, I smashed my wrist, causing no more than three fractures (I fractured the radius and the scaphoideum, and the impact from the scaphoideum splintered the ulna). By some miracle, it healed quite well, and I would claim to have regained 95% function. However, because some of my tendons (especially the dorsal radio-ulnar ligament) as well as the scaphoideum, are slightly out of position, I had to give up rock climbing and bouldering. Some strength are simply missing, and in certain positions, my hand will almost go numb, letting go of all force. Something is out of position, hence certain movements can’t be done properly. Translated to your ‘healing long’, it may seem like something in your ankle is out of position, and hence your gastrocnemius can’t be used properly.
At least, so goes my theory. I wouldn’t take it at face value if I were you, but try your PT, and see what kind of reaction you get. Perhaps mobilisation and manipulation of the joint is all it takes?
Happy healing, and good luck!
Fascinating input, Tord — the theory and the data on femoral shortening both! I’m not persuaded yet, but I’ve only had a few minutes to get used to it. One bit of evidence for the reality of healing long is that many of us who think we’re experiencing it (including me on my left, ATR#2, side, with my Gastroc), can clearly see that our calf muscle (my left Gastroc) is higher — more tightly contracted — than my other one when I’m doing a symmetrical 2-leg heel raise. I haven’t checked in months, but I think we’re talking about 1-2cm of difference in where the bottom of my Gastroc bulge sits when I’m “raised”. Can you imagine how far out of alignment an ankle joint would have to be to create an extra 1-2cm of slack in an AT that was exactly the same length as my other AT? It seems physically impossible to explain that asymmetry without appealing to AT length.
Also, I have my first-ATR OS’s word for it that he intentionally repaired my right ATR SHORT, and several professionals (a podiatrist and my current sports-med PT who’s trying to fix my right knee) have analyzed my gait and confirmed that it’s short (although I didn’t notice any gastroc asymmetry before my second ATR). So clearly, ATs can be surgically shortened, and I don’t see why they can’t also be lengthened through the trauma of an ATR-plus-recovery, e.g., by over-stretching while they’re recovering (op or non-op).
Finally, “many” kids are born with too-short ATs, and do abnormal “toe-walking” because they’re unable to stretch their AT-and-calf enough to get enough ROM to walk normally. My late FIL was one of those kids. Fortunately, there was a reasonably reliable surgical cure, even ~80 years ago when my late FIL needed it: They did open surgery on both his ATs, sliced them and left them un-attached, and casted him in or near neutral position. Both his legs “healed long” relative to his congenital condition, and he walked and ran normally for a long, full lifetime after he recovered from that childhood surgery.
In effect, after the surgery, he went through an intentionally “bad” version of non-op rehab, designed to _encourage_ healing long, instead of DIScouraging it! And it succeeded.
From that last example — and we’ve had a number of bloggers/posters here (and/or their parents) who’ve had a similar condition cured with a similar op — it’s obvious that our bodies can fill an ATR gap with new tendon to create a longer tendon than before. Your PT may be correct that our calf muscles can adapt to a longer AT (or a shorter femur) up to a point, but I see no reason to doubt that op and non-op recovery can both lead to a result that’s outside that range — especially with all the slips and falls that the average ATR patient encounters during too-long crutch-walking.
That isn’t to deny that PT and exercise and re-alignment can help us compensate for, and adapt to, the problems from a too-long AT-and-calf. I’m sure they can — again, up to a point. But we’ve had a number of people here who’ve finally thrown in the towel on non-surgical cures for “healing long” and gone for a surgical repair. And at least many of them were pleased that they did, after they recovered.
(BTW, I’m assuming that the patients who had their femurs shortened mostly did NOT have their ATs cut and shortened — or your PT’s example doesn’t illustrate what your PT thinks it illustrates.)
About your PT’s 3 alternative explanations for weakness that SEEMS like “healing long”:
1) A stretched calf muscle would NOT explain a muscle that’s visibly contracted more than the (MY!) other calf muscle. So no.
2) This one seems easy to dismiss if (as in my case) it’s easy and comfortable to do full-height TWO-leg heel raises. There’s nothing wrong with my plantar-flexion in my left ankle, I just don’t quite have enough power in my left Gastroc to pull my left AT up far enough to get to full height in a ONE-leg heel raise. If you examine the mechanics (leverage) involved in a heel raise, it’s obvious that the “mechanical advantage” keeps getting worse for the calf-and-AT as you rise up into the heel raise, just as the calf muscle is running out of contracting “room” to pull on the AT. That’s why it’s such a tough test, and why you can be pretty darned fit and strong, and still lack a bit of height in the 1LHR.
3) At least in my case, and for anybody else who’s got a higher-than-symmetrical (and usually skinnier) gastroc, the magnitudes of displacement make this explanation incredible IMHO, as discussed above.
Your PT does sound like an interesting character. Given how often “conventional wisdom” has later been proven wrong in the ATR field, there’s something to be said for an unconventional thinker!
Yea, he’s kind of a character
I tried to challenge him a little on your points. As far as I understood, this is his opinion:
#1. If you overstretch a muscle with low tonus, it may be damaged. i.e. parts of the muscle will not develop properly, and it’s hard to rebuild muscle mass. The result may very well be what you describe, and it may look like a longer tendon, while in fact it is part of the muscle being chronically atrophiated. I did not understand exactly how this works, but it seems plausible to me, at least.
#2. This would obviously be accompagned with pain and/or ‘clicks’. Should be easy to figure out. I have this at present, inhibiting me from doing a proper heel raise. I can lift some two inches from the floor (which is not bad 5 months post-op), and then I feel something blocking my ROM, I get a ‘click’ if I push it, and pain shoots into my ankle. I instantly loose all power, fallling heavily back on my heel. Considering the fact that I fell down with full force on my injured leg after the ATR, it is no surprise that I have additional ankle problems.
#3. If the joint is even slightly displaced, your ROM (or your resting position - see below) may be all fine without any WB, but adding weight to the equation changes the basics. This is actually the same I feel with my wrist. I have full range of motion, but I can not practically use the entire ROM if I handle something heavy. Of course, it’s easy to say that my wrist issue is caused by this, because it is also painful to use the entire ROM with significant weight added. i.e. the reason why I had to give up rock climbing and bouldering. This is quite similar to the point above, but without any ‘threshold’ and without any ‘click’. It’s just slightly painful to add weight in certain positions, and it seems like my nervous system blocks out - and I loose all power. What is more important with the joint misplacement theory, I think, is the fact that even a small misplacement may prohibit you from effectively using parts of your system (nervous or muscle or other), and hence it becomes almost impossible to regain tonus, mass and strength after the atrophy, and parts of your muscle will appear pretty much dead as a result. Obviously, other parts of your system may compensate for the loss, and devel its own issues as a result.
For your non-op comments he responded quite interestingly. He agreed that it was fully possible to ‘heal long’ in a non-op situation. More precisely, he believed this to be in the group of ‘non-op-non-heal’, and, to his understanding, this should be common among non-op full ruptures, while very rare in ops. In fact, he claimed that only a very poor surgery could produce the kind of scar tissue that would let the tendon be longer than it originally was.
From my understanding, he focussed solely on scar tissue as the cause of this problem, and he speculated that a long tendon with plenty of scar tissue was probably preferable to a normal tendon with same, as a normal tendon would be subject to much more force, and probably have a much higher probability of re-rupture than a longer one.
Pushed on this issue, he responded that non-op of a fully ruptured tendon should either produce a tendon lengthened by weak and problematic scar tissue, or be more normal in length, but at very high risk of re-rupture, because the scar tissue would be too weak.
I countered with studies proving that aggressive rehab of non-op patients gives at least as good results as less aggressive rehab of ops. He speculated that early mobilisation may inhibit the production of excessive scar tissue, and stimulate the body to automatically adjust length and strength before scar tissue formation deals too much damage.
He also mentioned that your ROM isn’t an important factor. Rather, the resting position when you lay down on your stomach with your feet hanging free is the relevant measure. You may only do calf stretches if your resting position is ’shorter’ than your good leg, and you have good muscle tonus on your entire calf muscle. Resting ‘long’, in his opinion, should indicate low tonus on all or parts of your calf muscle, or a failed non-op treatment (excessive scar tissue, as explained above - similar to healing long).
Lastly, he emphasised, strongly, that this was his gut-feeling. He has no particualr expertise or experience with ATR, he said, but this is his gut-feeling - based on 60 years experience with ankle, knee, and hip patients. His expertise is actually occupational treatment of disabled people and treatment of paralympic athletes, as well ankles, knees, and hips. He is a former paralympic athlete himself, by the way, as he is blind.
He is surprisingly updated on ankles, hips and knees, as well as novel techniques developed within manual therapy, occupational therapy and osteopathy. His latest ‘project’, it seems, is to update himself on the wonders of barefoot running. I don’t think he is fully convinced, but his distate for certain podiatrists who claims that the human body is imperfect for running keeps him interested.
As I said, quite a character
Hi Tord and Norm - and thanks for the input…
Per your PT’s comments Tord, I think the one that makes the most sense to me is misalignment in the ankle, I definitely have that when weight bearing - but my feeling was that this was a result of the weakened calf, rather then the cause. I know my PT has had me on my stomach with feet hanging to check alignment and function - if anything was really out of whack, I’m assuming he’d tell me. BTW- like you, climbing is one of the things I have had to give up, pretty difficult if you can’t step up on one side.
The ROM (#1) theory might hold some water as well. I generally feel an achilles stretch in the front of my ankle (as a pinch) before I feel it in the achilles, so I think there is definitely some blockage going on at some level. But again, I would think this could be from an elongated achilles not engaging soon enough in that flexed position.
I am really hopeful that I can get this back to good walking and running function through exercising it with the sole intention of engaging that gastroc… I did more or less drop my PT exercises at 6 months - with the thought that if I am out running and biking and hiking, etc. strength would return. Right now I am on a more or less self-directed 6 week program to see if I notice some kind of improvement - after that it will be back to speculation and the looking at options.
Tord, that’s an amazing post!! I’m glad you smacked him with the evidence when he claimed the opposite! Somebody once said that the first principle of Physics is that “If it exists, it must be possible.” And excellent and very reliable non-op “repair” of complete ATRs has been proven to exist.
In my case, with a high Gastroc during DF and weak DF, I suppose it’s conceivable that the “too long” part is not my AT, but a weakened length of muscle tissue at the bottom of my Gastroc. But any claim that this arrangement would be fragile and prone to late reruptures is clearly false, as late reruptures (after ANY ATR treatment) are virtually non-existent. We’ve also had a few “healed long” people going for AT-shortening surgery, and you’d think that SOME of those surgeons would have noticed the REAL problem, and told their patient, who would have shared here. But no. I’ve searched some of the ATR literature a few times myself, and never seen a word about this muscle tonus issue, but that doesn’t prove it’s not published — much less that it’s not true.
We’ve still got way more Qs than As, and the fact that the “establishment” almost surely still believes some falsehoods (not to mention the average practitioner) does NOT mean that every unconventional theory is true. The trick is to find ideas that are true, or at least those that help solve your problems!
There’s an important lesson from back pain: Whenever I’ve been exposed to the founding truths of Chiropractic, some of them have seemed obviously wrong. Yet lots of people I know have had personal success from Chiropractors, ranging from “relief” to “magical cure”. And 1 or 2 big studies of back patients has demonstrated that those who go to Chiropractors are generally better off and more content than those who go to MDs. Me,
I’d be happy to have my “trick” right knee cured by anybody — including somebody who’s convinced the Earth is flat or the Moon is made of green cheese!
I’ve also spent some time singing professionally, and studying voice. THAT’s a field where teachers and coaches often describe physical mechanisms that don’t really exist — but thinking they do sometimes produces great results!
Disclaimer: I didn’t read all that. I skimmed it.
Interesting to hear your doc’s point of view.
I agree you can have a short or long achilles tendon. A long tendon will have a high ROM measurement. Tord could have a long AT, but he feels the stretch in the front of his ankle so we don’t know how far the achilles can go before stretching. My guess is he is still not long. Tell your PT you feel the stretch in the wrong place and he should know how to help. That’s a joint problem.
Most of us that lack strength I don’t think actually have a long tendon, although it’s possible. Low tone could be an issue. Gastroc/soleus rely on tone since they are mostly type I (slow twitch, balance, high tone) muscle fibers. Tone was an issue for me and I was checked by my PT and have pictures of me lying face down with ankles hanging off the table. My involved leg has lower ROM but rested longer by about a centimeter. That was at about 9 weeks and now isn’t as much of a problem. Tone in part is used for balancing on that leg and 2 shoes fixes that with balance training in PT.
My biggest question is why is the soleus coming back better than the gastroc? The soleus is more type I than the gastroc and relies more on tone. So why would a lack of tone to the gastroc be my problem?
I continue to strength train the gastroc and I’m seeing slow but steady results.
Hey Mike.
I’m interested to know what your “gastroc-centric” strength training consist of?
Anything with a straight knee. And lots of it. The rest depends on how strong you are. A few basics that you may be too strong or weak for:
Theraband plantarflexion
Two legged heel raises
One legged HR
Machine heel raises (gives a more specific weight if you have a good machine)
Negative (eccentric is the correct word) heel raises
Hopping straight kneed (maybe on a machine like a leg press since you’re probably too weak for full body weight)
In real life we don’t use the ankle with an always-straight knee, but it can be emphasized if the gastroc is behind. My gastroc is typically worn out after a good workout, which didn’t always happen in PT. That may be more just the way it goes or a need for more gastroc training.
I also do things like layups (basketball) or ladder drills or other modest plyometric activities. I’m still trying to keep the knee as straight as possible without altering the basic mechanics of jumping.
I plan to eventually do box jumps, but I’m not strong enough yet. Done properly, they are probably one of the hardest plyometric exercises for the calf.
Why the @#$% is that comment awaiting moderation? Dennis??
Let’s try it with only ONE smiley:
Smart and sensible stuff, Mike!
It’s interesting to try to apply different approaches to ATR patients with different problems — or even different levels of exactly the SAME problems. E.g., I think both PabloMoses and I (and Mike?) have lengthening a/o strength deficits with straight knee (Gastroc), but less or no problem with bent knee (Soleus). But PM has real functional problems, and I’m happy with my function — except for my right knee, but let’s ignore that for now.
So for me, sports may well be strengthening my Soleus as much as my Gastroc or even more, which is OK with me. But for PM, it’s important that he strengthen his weak link, so he’s got to work hard to isolate his Gastroc, using some of the approaches Mike has outlined above. I suppose I could try them, too, to see if I could get my left leg closer to “perfect” — but I think I’d rather do other things (including stretching my right quads and gastroc to try to fix my right knee!). At this point, I’ve given up on perfection!
And it WORKED!! So putting in two smileys is enough to make this page reject a reply/comment until it’s moderated. AAARGH!!
Agreed. I am definitely functional. Any complaints I have are just that I can’t jump as high. No other part of my life is seriously affected right now. It could be worse. PM, you might have more than gastroc problems if you’re still having the problems in the post. Sounds like soleus might be gone too.
%&#£@?
Still awaiting moderation. Nevermind then.
Tord, if you copy your awaiting-moderation post, and paste it into a new “Leave a Reply” window then delete some smileys and/or URLs (or trim out the http and www parts), it will probably get through without waiting for pablomoses to approve it. As I mentioned above, two smileys seems to be enough to put a reply into Limbo/Purgatory here. And maybe on most pages here?
Hi Pablomoses,
Not sure if you still read this but wondering how everything has worked out with your ATR. In reading your post I have exactly the same symptoms at 7 months.
Kevin