pete0609’s AchillesBlog

         Just another AchillesBlog

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.


  1. Pete -the update sounds great, but that report is certainly concerning! I’m so curious to hear the results of your upcoming MRI, and hope that everything is ok. Which fitbit did you end up purchasing?

    [WORDPRESS HASHCASH] The poster sent us ‘0 which is not a hashcash value.

    Comment by sporti — May 28, 2014 @ 10:31 pm

  2. Pete, we’re near each other on the ATR recovery timeline (I’m just 1 week ahead), so I’m interested in your progress. I’m confused with how you could be doing so well at this stage of recovery and then trying to reconcile that with your recent ultrasound report. Something doesn’t add up here and I hope it’s the report that’s wrong. Best of luck. -David

    Comment by davidk — May 29, 2014 @ 12:40 am

  3. On my blog I tell the story of my 3 weekly post-ATR Ultrasound exams. They were done to guide PRP injections, but as long as I was there, I asked the fancy sports-medicine doctor what the rupture looked like. The guy is the founder of a fancy sports-med clinic and (IIRC) the Chief MD of the Toronto Maple Leafs pro hockey team — definitely no slouch. But each time he looked, at 1-week intervals, he saw a different ATR!! I still have no idea which of the 3 completely different descriptions (if any!) was accurate. It seemed a lot like describing the shapes of clouds.

    I’ve also had an experience with a series of 3 monthly MRI — not of my leg, but of my Dad’s spine — that were very dangerously and seriously Just Plain Wrong, apparently with no relationship to reality. I think that’s also described on my blog page. He was almost rushed into emergency surgery to solve the serious problem (which the experts diagnosed as a massive infection of the spine) detected by the first MRI — a problem that kept getting WORSE with each monthly MRI exam, as my Dad’s terrible backache gradually disappeared, never to return again!! Again, I have no idea what caused that huge shadow on the MRIs, or why it grew bigger and darker and scarier as everything else about my Dad’s spine got better and better!

    MANY expert sources and studies have now shown that MRIs of the spine are generally much worse than useless, though I’ve never seen a good explanation of WHY they’re so WEFT (= Wrong Every Time). One great episode of a great Australian radio show — The Health Report with Norman Swan — dealt primarily with chronic back pain. One segment highlighted two studies on spinal MRIs. One study subjected a random group of healthy active young folks (no back problems at all) to spinal MRIs, and found serious “crippling” problems in (IIRC) MOST of them!!
    The other study took a group of chronic back-pain sufferers and gave them all spinal MRIs. Half of the patients (chosen randomly) were “forgotten”, no follow-up about the MRI. The other half got to see their MRIs and discuss them with a specialist. The forgotten patients did significantly better in long-term follow-up about their backs!!

    So I’d take ALL these diagnostic tests with a big grain of salt. If your leg is getting stronger and feeling better and working better, I’d stay with the program.

    Comment by normofthenorth — May 29, 2014 @ 3:38 am

  4. Hey Pete, it sounds strange to me that your DR ordered an ultrasound and didn’t perform it himself. Mine brought in the ultrasound machine right into the exam room and showed it to me himself. He also showed me that the tissue at the tear at this stage was different from the surrounding tissue, which is normal, but couldn’t say what type of tissue it was and he wasn’t worried about it at all. The only thing he said he could do with the ultrasound was verify that the gap from the tear had indeed closed. It sounds to me like whoever wrote the report was just taking a guess at what the different tissue could be. The MRI should be much more clear. I had a similar situation in which the Orthos couldn’t tell if it was a complete tear or not without the MRI. There was just a fiber or two holding it together, and that was clear in the MRI.

    Also, be careful with barefoot shoes at this stage. They are definitely the best for strengthening the lower leg, but that is when the lower leg is perfectly healthy. They put a high amount of stress on the calves and achilles and offer no protection or stability for slight changes in elevation. All good when everything is working optimally, but not so much during the high risk transition weeks. Personally, I’m just walking barefoot in the house and putting on something with more protection for longer walks outside.

    Comment by Roark — May 29, 2014 @ 11:55 am

  5. Hi - I am in the situation as you do! Swells up during the day and cycling 1 hour each day too! Can I suggest compression socks at night? It really helps and the next day my foot is much normal until i start working out/ walking around…then it starts to swell!
    As for shoes - i am wearing Nike Roshe Run trainers… my PT said its very good and supports my ankle well!
    All the best!

    Comment by soj9 — June 2, 2014 @ 4:42 pm

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