pete0609’s AchillesBlog

         Just another AchillesBlog

June 4, 2014

11 week update - Fatty inclusion

Filed under: Uncategorized — pete0609 @ 9:17 pm

So i am in week 11 now and in my last post i mentioned that ultrasound imaging has discovered something that could be fatty tissue in my tendon. My doctor was concerned about it (a fat pad could inhibit tendon healing in that section) and sent me to have MRI and x-rays done. Diagnosis was confirmed and there seems to be a fat inclusion in my tendon (0.4cm x 1.6cm). It remains unclear where that fatty tissue came from, but in the course of tendon degeneration it is not totally uncommon that something like this would develop, my doctor says. It probably was already there before i ruptured my AT. He discussed the problem with a sports surgeon, who recommended to just keep doing what we’re doing and see if the tendon heals fine anyway (they seem to think there’s a pretty good chance). After 6-8 weeks we could consider surgery depending on how well i healed. Depending on the healing progress until then, the surgeon would either just remove the fat pad, or repair the tendon, which would probably put me back to day 1.

The MRI also confirmed i only had a partial rupture (40-50% of the initial tendon still intact), and old partial tears of the PTFL and ATFL, two smaller tendons in the foot. I don’t know what to think about that. I’m not sure i wanted to know how messed up my foot really was.

I kinda wish no imaging would have been done (i’m right there with you, Norm). Everything will be fine and I probably never would have known the difference.

Anyways, i try to keep calm and carry on. I got myself the most expensive socks i’ve ever bought - compression socks (1 pair of Bauerfeind - i paid $125). They do an amazing job, worth every cent. My leg swells up a lot during the day, and the compression socks help to keep this within certain limits, they do it amazingly well. I wear them during the day, not at night. When i take the sock off in the evening, my leg looks almost the same as it did in the morning when i put it on.

Swelling in general hasn’t been a problem for me at all while i was still in the boot. But it really started once i was out of the boot. I got myself some big ice packs that i can wrap around my leg (my PT says to not apply for longer than 20 minutes at a time, but it feels so good).

My fitbit (sporti, i got myself the flex) helps me counting my steps per day. After gaining some experience i lowered my daily target to 8000. The initial 10,000 were too much, together with the heel raise exercises and 45 minutes on the spin bike with some resistance (pedaling basically only with the bad foot), i was more sore and for longer than i wanted to be. I guess i’ll increase the target again after some time, can’t say when, though.

My heel raise exercise - i stand on my bad foot, the other one in the air and both hands on the counter. I push myself up with my hands (while trying to help with my foot) and then lower myself back down slowly, while trying to put at least some of the bodyweight on the bad foot. I do 15 reps, 3-4 times per day.

I still have physio twice per week. It helps to keep pushing myself, but also refraining from things i shouldn’t do.

One other thing i wanted to mention was kinesio tape. When i saw my doctor today he asked me to walk for him and said i walk funny (I  did and still do, that hip drop…). Obviously my fibula bone (in the good leg!) started pushing out to the side, i felt the bump in the skin, probably from walking in the boot for so long. So he put some kinesio tape over that bone to push it back in and instantly my walking was better, more straight. Thought that was pretty cool.

So in general my rehab is going okay, my leg/calf/tendon still feels fairly tight most of the time, i get next to no push off in my bad foot (maybe a little micro push off), but it’s all still within what could and should be expected according to uwoprotocol, which i am following.

And well, I am in 2 shoes completely now. No more boot.

I am looking forward to reading your comments.

May 28, 2014

10 week update - fatty tissue in retracted tendon gap?

Filed under: Uncategorized — pete0609 @ 4:56 pm

I saw my doctor today - he had asked me to have an ultrasound done on my bad ankle, we looked at the report today and he seemed concerned with the result. Next thing is that he wants me MRI’d, which is probably going to happen next week. I can’t make much sense of this ultrasound report today. The report says, amongst other things, that a) i might not have had a full rupture and b) there could be fatty tissue filling the gap, which really concerns me. How likely is that?

This is what the ultrasound report says (9 weeks after start of treatment):

“The achilles tendon has a normal appearance as it attaches to the calcaneus. Just proximal to this, there is some moderate tendinopathy. Approximately 5.0 cm proximal to the attachment of the achilles tendon to the calcaneus, there appears to be a tear with retraction of fibers extending over a variable length, on average about 1.7 cm. there is some echogenic or likely fatty tissue extending into the retracted tendon gap. The tear definitely extends through the ventral aspect of the tendon. I think there is a small slip of intact tendon fibres along the dorsal or posterior aspect of the achilles tendon, about at most a couple millimeters thick. There is no evidence of hypermia across the area of tearing.

The tear is very deep and extends across the full width of the tendon. I think there is a thin slip of intact tendon fibers across the dorsal aspect of the tendon. There is some echogenic material filling in the retracted tendon gap suggesting hemiated fatty tissue and/ or fibrotic tissue.”

So i am not sure what to think about this report, also because the doctor did not want to say much. He is also concerned about the “fatty tissue” remark and wants to exclude this possibility by having an MRI done. If there really was fatty tissue, it could inhibit the tendon healing, which concerns me, of course. I hope it’s just collagen. According to doctors in the family Differentiating the inflammatory tissue of normal healing and a fat intrusion should be very difficult on ultrasound.  Fatty infiltration is usually associated with muscle atrophy.

Other than that i am progressing according to schedule, I guess. I am out of the boot and walking in 2 shoes during the day, but i wear the boot at night. I transitioned from the vacocast into two shoes and I can recommend using a hinging boot. The adjustment in the vacocast can also be done very incrementally (5 degrees at a time), which I found helpful. I brought it down from 30 degrees (week 6) to hinging +10/-10 (week eight) gradually, took two, sometimes three days for each step. I still walk with a limp (of course). Actually Two days ago was my first day completely out of the boot. As exercises i do two legged heel raises with support (i hold on to something to keep my balance), but there is not much push off coming from my bad leg. I ride on my spin bike about 1 hour in total per day, with some resistance to train my bad foot and gradually work on strengthening. As with most other people here progress is very slow and not much is happening day after day, but at least i’m walking in 2 shoes. My foot swells up a lot during the day, but that’s usually all gone the next morning. When walking i try to walk slowly and really focus on getting at least a tiny bit of push off in the bad foot.

As for shoes i got myself some NB Minimus shoes because my PT said it would be best if i walked barefoot most of the time. I can’t do that in the office, so i bought some shoes that claim to be close. I bought the minimus ones that have a bit of a heel lift (4 mm).

I liked sporti’s approach tracking his steps with a fitbit. I got myself a fitbit, too, and defined my threshold at 9000 steps per day for now (a healthy person should do about 10,000 a day). I try to get to the threshold every day (manage only sometimes to do so…) and focus on pushing off with my bad foot. Along with the cycling and the other exercises this is my program for now. I feel good about it and i get the feeling, now that i have done this for a little over a week, that there is incremental progress.

As always, i am very interested and looking forward to your comments.

May 5, 2014

Six week update and Connected!

Filed under: Uncategorized — pete0609 @ 8:56 pm

After a very disappointing meeting with the surgeon in the hospital (it lasted 90 seconds, he didn’t even look at my foot and gave some strange recommendations that weren’t even in line with his own uwoprotocol - i am not going back there, just a waste) i saw my sports doctor today and that was helpful.

I am at six weeks post rupture (non-op) and my sports doctor felt my tendon, said he could feel it’s connected again and where the injury was he said he could not feel a dent or divot. I guess that’s good, but probably normal at this stage. I’ve never had much of a swelling, rarely iced it, but always took my foot out of the boot and put it up whenever i could (and did the ROM exercises).

Like probably most people I have this lump around the injury and he told me to massage it. Use some oil to not break the skin, but to somehow loosen the scar tissue, and massage it hard with your thumbs. Kinda hurt when he did it, but the doctor said it’s necessary to break down the scar tissue so the tendon can move better.

He also really wants me to get going and move around, ratchet down the angle of the vacocast a notch or two every 3-4 days. I should be at 0 in two weeks, then take off the rocker achilles sole and put on the flat sole, then and start hinging. Then transition into two shoes. He said to do what i can tolerate. If am sore for an hour or maybe two after changing the angle, that’s fine. If i am sore for longer than that, it was probably too much, so i should listen to my body and see what i can handle. His important message was to get the tendon somehow to move and stretch, but not too much.

I also started doing very gentle seated heel raises. Unbelievable how difficult this has become.

May 3, 2014

Ruptured March 19th - non-op route

Filed under: Uncategorized — pete0609 @ 9:22 pm

Hi there,

I am a 42 year old Toronto expat from Germany and I ruptured my Achilles’ tendon on March 19th while playing soccer. I am very grateful that I found this site early into the deal, some great and helpful comments from Norm and Kelly (and others, of course) that that helped a lot to better understand what that whole protocol is about (my doctors never bothered - in 4 visits to the hospital I was seen by 4 different doctors and each had about 90 seconds of time for me). So hello everyone and thank you to all of you (Dennis, thank you for the site), probably also in the name of all the people who read and benefit and never get around to sharing their own experiences.

I’m a classic, felt as if hit by a baseball bat in a “dead ball” situation when about to do that free kick of my life. Felt the pain, heard the pop, rolled over and was done for the night. At the time I wasn’t yet sure what had happened (had my suspicions, though… ), drove myself home that night and to the ER in the morning. By then I was 99% sure I had ruptured my achilles and I was right. I received a back slab in the ER and was told to come back the next day to see the surgeon in fracture clinic.

Since I am from Germany and the non-op route is not yet very popular there, I expected to have surgery done (also because the ER doctor said the ends of my tendon were 7 cm apart). But in the fracture clinic they refused to do it (I sort of asked if they would do it anyway, but I figured if it’s not standard procedure anymore they don’t have the experience I would want to see in my surgeon). So I gave in, also because I didn’t want an uninterested newbie mess around in my leg. I am fine with the non-op route, my only concern is that no doctor has ever checked if the ends had approximated enough to justify the non-op route (what do you think, Norm? - FYI- I have been to Sunnybrook hospital). Still not sure if that was the best decision for me.

I was given the aircast boot (with the biggest heel lift they had, 4 wedges), and I switched to the vacocast 10 days ago (it’s German engineering, and that’s what I wanted for my foot…). First I was a little disappointed after this boot had received all these rave reviews. I couldn’t walk in it and actually went back to the aircast, but now I am mostly in the vacocast. I am hinging now between 25 and 30 degrees after I was told during my last visit at the hospital to take out one wedge (referring to the aircast) yesterday. I am planning to go to 20 and 30 a few days from now. So far everything feels okay, some tension in the tendon, but I guess that’s supposed to be there.

I have been to the PT since week 3, I also got myself a spin bike and I do between 20 and 40 minutes a day since week 5. Feels good, my PT okayed it and also understands that I want to get back to sports (biking, soccer, skiing, playing with my kids) ASAP.

Swelling and pain has not been a big problem so far, I guess this (pain, at least) might change once I get into 2 shoes. I have a fairly hard and big swelling/knot in the area where the injury was. My PT told me to massage it with a rolling pin 2-3 minutes a day along with all the ROM exercises. I am FWB since two weeks and according to the UWOPROTOCOL I think I am where I should be.

I am planning to have an MRI done (or at least another ultrasound) because my biggest concern is the big gap I’ve had (7 cm between the two ends). Do you guys have any opinion on this? My fear is just that a lot of scar tissue will form (more than would have with more approximation) and I lose more tendon strength and smoothness than I would have with surgery.

Other than that my recovery is coming along fairly well I think, I could work from home a lot (still do - can’t drive since it’s my right foot) and my family and also my employer are very supportive. I have never seen my kids this much since we moved to Canada 20 months ago, so that’s a huge benefit of this injury. It also happened at the right time of the year - the ski season was already over, and since this winter drags on forever and not much to be done outside I am not yet missing all that much. It’ll come, though, I’m sure. We all know it’s a long recovery. But there are definitely benefits if your life comes to a full stop in such a way.