Wow, 14 weeks

Can’t believe it has been 14 weeks today since surgery. Those were not the best of times. You never think the time will pass, but it does. These days, it is all about building strength in the calf. I walk normally now, but I need more push off to get back to athletics. So it is heel raises and more heel raises, the two footed variety on the way up, majority of pressure on the bad one on the way down. I don’t even want to try one leg yet…need to see some more muscle back there first. I did PT 2x a week for a few weeks back at week 8 and now I go once a week or every 2 weeks, depending. I still have a hard spot towards the top of the scar, so I am hoping the PT massage will help break that up. Other than that, I think I am fine on my own to do the exercises…just have to make myself do them more consistently. I try to go for walks on nice days and focus on pushing off - maybe 2 miles over varied terrain. I got a heck of a calf workout last weekend wading a freestone river flyfishing but I can’t get away to do that as often as I would like. I am horribly out of shape cardio-wise - found that out doing yardwork last weekend. Anyone have any tips for gaining strength faster or guidelines for when to return to sports? ach0423101

26 Responses to “Wow, 14 weeks”

  1. I have such bump , based on your pic, even I didn’t have op.
    It’s getting larger after exercises and smaller if foot just is relaxed.
    Do you think that PT can make it go away?

  2. They tell me it is scar tissue…no idea if that is possible without surgery. Seems plausible though since there was tearing in both cases. My PT says it will eventually go away, reabsorb/spread out, and that the massaging helps with this process. I have no idea if it is true, but it sounds reasonable. My spot doesn’t seem to change much with activity, it is just there.

  3. My fave rule-of-thumb for return to “high risk” sports is from my ortho surgeon 8 yrs ago (1st of 2 ATRs): When you can do a bunch of 1-leg heel raises without grunting or groaning, you’re ready to “go for it”. In my case, I was there for sure in around 10-11 months. Maybe sooner, but I didn’t care ’til then, when the next volleyball season started. (Before that I was bicycling and sailing small sailboats, neither of which was high-risk for my AT.)

  4. Hi Pete

    My thoughts:
    1. The bump is collagen III, aka scar tissue. Your body will reabsorb some of it, replacing it with collagen I, the normal tendon material. The amount of reabsorption of III and buildup of I depends on your massage and exercise.
    2. The key to return to sports is rebuilding the calf muscles, especially the gastrocnemius, which does the quick work. So anything than produces that athletic “burn” there is good. The burn is the muscle building lactic acid, meaning it is building srength and stamina. You should feel that gastroc fire and build the muscle definition. My PT got really excited by mine this last week during dual toe rises.
    3. At 14 weeks you are aware that your tendon is not yet at full strength. Could be from 25- 50 %, depending on your PT protocol so far. Estimate normal strength by what you can press without straining with the ball of your good foot on a bathroom scale. What you can press (again without straining) with the recovery foot is an indication of the strength of the calf muscles, not the tendon.
    4. Your tendon won’t be full-strength until 12 months of so. But that should not prevent you from doing sports beforehand. The key is to not overstress the tendon by slipping and yanking the foot around, or getting kicked.
    5. In addition to breaking up scar tissue, massage enhances blood flow, and thereby healing and strength building. I do it myself everyday when watching TV, reading, etc.
    6. Pressure on toes during walks are good. I pressure-walk my dog on the beach 1-2 miles a day. I’m at 13 weeks post-op, pressing 116 lbs. on the recovery foot, playing light softball and tennis.

    Lou

  5. Lou, What (if any) footwear do you have on for your beach walks?

  6. Hi Notsorad

    I use inexpensive ($30 at Kohls) Reebok basketball sneakers - mainly for the side protection. I bought them when I transitioned to 2 shoes because they are cut low in back so there was less rubbing of the incision and that scar tissue bump.
    My understanding is that the tendon is repaired with collagen III (scar tissue) in about 8 weeks from ATR, whether surgery or not. Collagen III is repair material, but much weaker (the 25 - 50%) I mentioned earlier) than collagen I, which is where we all want to wind up. Relying on just PT means a long time to 100% collagen I, aka 100% strength. So a lot of exercise and massage to hasten the transition, and reduce that scar tissue, is the quickest way back to unlimited sports.
    The sneakers mentioned allow me to push off, yet give me extra support and protection. When playing softball or tennis I use a Futuro ankle brace that has 2 hard plastic side inserts to protect the achilles on each side. I have trained myself not to push-off on the recovery foot.

    Lou

  7. My last paragraph sounds contradictory. I push off on the recovery foot on the beach walks, where it is safe, but not when playing softball or tennis.

    Lou

  8. Lou, thank you for your reply. I am seeing beach walks in my near future. I think I’ll start off with the hiking boots and work into athletic shoes. I like the idea of trying Bball shoes.

  9. Sully, I don’t understand your
    “Estimate normal strength by what you can press without straining with the ball of your good foot on a bathroom scale.”
    Can’t you lift all your weight (and more) on the ball of your good foot? If so, the scale won’t tell you how strong that foot is — unless you load yourself up with barbells until you can reach that foot’s “load limit”, you’re not getting the answer.

  10. Hi Norm

    No need to use barbells. You can hang onto a door knob, stair handrail, etc. Anything to restrain upward force. Just do not strain, you don’t need a hernia somewhere else.
    And yes, the fact that I can do one-foot raises on the good foot means I can lift all my body weight there.
    That’s how I measure progress to ability to do single toe rises on the recovery foot. When the non-straining pressure force (now 116 lbs) approaches my entire body weight I should be able to do the single toe rises on the recovery foot safely.
    Until then I work at the levels I deem safe, but my gastroc muscle will gain strength by its use at force levels at or slightly above the current non-strain limit.
    I want to transition to collagen I, the natural tendon material, ASAP. Relying on scar tissue (collagen III) to hold my tendon together for the next 12-18 months seems to me to be a bit risky. So everything I do is to:
    1. strengthen the gastroc and soleus muscles (calf), and thereby the tendon,
    2. increase blood flow into the tendon to get nutrients in,
    3. get edema (swelling) out of the ankle,
    4. use the natural pumping action of the calf muscles.

    PS. I’m not a doctor or PT, but just a fellow ATR recoverer.

    Lou

  11. Thanks, Lou. I’ve never tried to hold myself down while pushing a scale down to max force from my GOOD foot. What kinds of numbers do you get when you do it? (I would have hoped for a number near the scale’s 300-pound limit. Optimistic, I guess.)

    My healing foot is just flirting with my body weight now — around 175-ish compared to 185-ish, at 19 weeks. That’s close enough for a “perfect” stride (when I concentrate), but not a 1-leg heel lift. It’s been close for weeks, with quite slow progress, despite a fair amount of work on it.

    Interesting nuances, too: In a good moment, I can hold my weight up on the ball of that foot with my knee bent, but not with my knee straight! Also, walking perfectly “normally” takes some effort, but walking perfectly while swaggering from side to side (like a gangster or a rebellious punk) is WAY easier!!

    8 yrs ago (1st ATR, with surgery), it unfolded quite differently, I’m not sure why: 3 casts, slow schedule, then a hinged boot, walking and bicycling, very little physio and maybe no 2-leg heel raises either. Then at ~17 weeks, I could “suddenly” walk perfectly in bare feet! I don’t remember it being a struggle, it just worked.

    My physio and I were so proud, she paraded me up and down the length of the U. of Toronto Sports Medicine Clinic in bare feet! (A young woman who’d had the surgery a month before me still couldn’t walk right, and I was already a geezer!)

    Then back to her station for physio work. At the end of the session, she told me to do 1-leg heel raises. I told her it was too soon, because I could never do 8. She said “Just do as many as you can.” Bad idea. I did 3 or 4, grunting and groaning, and I couldn’t walk properly again for a full month, because of the brand-new pain at the back of my heel!

    I spent that month back in the hinged boot, walking and cycling and even running, as the new pain gradually faded. When the pain went away (21-odd weeks post-op), I was walking perfectly again without any special effort.

    It was another ~5 months before multiple 1-leg heel raises were easy (and I returned to competitive volleyball), but I don’t remember spending a long frustrating period just barely being able to walk perfectly, or pushing a scale at ALMOST my full body weight.

    It’s possible that the main difference was that I spent that crucial period in the (hinged) boot, whereas I went to “2 shoes” right after 8 weeks this time — so I’ve been watching this pot try to boil! Or there may be a difference in the way my calf strength is recovering. But I’m consciously working much harder at it this time, so it’d be funny if the recovery was slower! Maybe 8 yrs of age is a factor, though it hadn’t slowed down my volleyball play before the ATR. . .

    I love your info, BTW! I just couldn’t picture how you got a true reading on your good calf strength.

    I’m not a doctor or PT, either — and I don’t even play one on TV!:-) My “expertise” comes partly from reading studies and partly from the experience of tearing BOTH ATs, and having quite different protocols applied. This time I went with NO SURGERY, using the same rapid protocol as one of the modern studies that showed NO BENEFIT from surgery (and lots of problems from surgery), when it was compared to non-surgical immobilization using a careful and scientific approach. (Details on my blog.)

    My progress has generally been MUCH faster this time, without surgery(!), though it has slowed down in recent weeks, while I join the large group here that’s waiting to build up enough calf strength to do a 1-leg heel raise.

    I think there are two simple take-home messages from my experience and the good studies I’ve read: (1) There is no good reason to undergo ATR surgery — unless maybe you’re getting the experimental surgery that two Japanese surgeons have been using for a year or two; and (2) There is absolutely no reason to follow a slow protocol, e.g., to spend more than 2 weeks NWB or more than 8 weeks on crutches. Some suffering is avoidable, but the other kind should be eliminated.

  12. I saw my ortho again today as it has been 6 weeks since the last time. Though I feel like I am behind in my recovery because I can’t do a single leg heel raise, every time I see him, he gushes about how well I am doing. This time he said that the simple fact he could muscle definition in my calf (14 weeks?) means that I am ahead of the game. He said I would be an “outlier” if I could do a single heel raise at 6 months! Very strange and conservative from a guy that had me FWB at 10 days post-op. He said that the hard spot under my scar could take up to a year to go away, but that PT massage could help. (I took that to mean not much, so maybe it is more a question of time). He said I could play some careful tennis if I wanted to and still stressed that I not push the dorsiflexion - don’t stretch that side. He said he has never seen anyone heal “too short” so apparently he is still concerned about healing too long. Odd.

    Anyhow, strengthening is the name of the game and maybe I will mix in some light sports. I have seen on this site some folks mention braces they wear when exercising. Are these just protection from getting kicked or do they prevent too much dorsiflexion? Would a regular ankle brace help somewhat?

  13. Hi, I’m on 5 months and still can’t do a single heel raise. Can do almost half of it if I have my hands on a wall or something. It’s getting close day by day.
    About the scar, I still have that hard thing too and my pt said that this would take very long to go away. I still have another 2 sessions and then i’m on my own and the program he’ll give me to exercise on the court.
    About support..i have wondered myself if it would be nice to tape my ankle or brace it. I’ve searched on videos on how to tape it, but it doesn’t seem convenient. I have -again- asked my pt and he suggested that i shouldn’t ever tape or brace it, especially tape it, because then my tendon will become dependent on taping and it would be then easier to injure again. I say it makes sense.

    That was my thought exactly, mixing in my sport, so i started joining my team’s practices, of course i don’t overdo and stop where i feel i have to. ICE at the end and elevation help a lot.

    Don’t worry, I think you’re on the right track.

  14. Hi Norm

    I got to about 260# on my good foot, not pushing it. Your measurement of almost body weight from your recovery foot sounds great!! You will be doing the 1 foot toe rises safely very soon! Congrats will be in order.:-)

    Regarding knee bent, knee straight: Your calf muscles - soleus and gatrocnemius, have maximum tensile force at certain lengths. The knee bent stretches the soleus , whereas the knees straight the gastrocnemius. It won’t matter once you rebuild strength beyond your body weight.

    I totally agree that early weight bearing, massage, and putting weight on the ball of the foot, are keys to recovery. The sooner we get rid of the weak hard scar tissue and replace it with softer, stronger normal tendon collagen, the better. I also went 2 shoes early, at 7 weeks. PT said that 2 shoes would give full ROM and it did.

    Pete:

    FWB does not put any tension on the AT if your foot is properly immobilized in a cast or boot. Your doc is right, most people are put on conservative PT protocols that will not develop strength as fast as is possible. So if you want those single heel raises before 6 months, you need to do those strengthening exercises yourself.

    Great that your doc allows “lite tennis.” Just train yourself to let the tough shots go. You’ve got a great excuse now, but don’t expect any sympathy, or easing up, from your partner or opponents. The first smash will feel so great!
    I use the regular Futuro (available at CVS) ~$15 brace because it has 2 hard plastic inserts that protect the tendon. I also use it playing softball. Never know when you might get a shoe impact (your own or another player), or hit a foul ball.
    Some tennis players allow both sides a double bounce, but I found by playing doubles coverage was fine without the double bounce. I found I had to learn to serve without the forward lunge, and the backhand (I’m right-handed) was weak because I could not push off on the recovering left foot. I’ve started using a softer strung racquet to compensate. Seems to work. I’d like to hear what you experience.

    Lou

  15. 11 weeks out kind of a plateau for me. Everything going well. Kind of overdid it this weekend moving from one house to another but tendon survived the move:) Tried my first one legged lift last monday at PT and could only raise up 75% of good leg. Still not there yet. So we are concentrating on new exercises for strength. Tendon feels great, heal still hurts at end of the day from the boot, doc says the one thing about the boot is it aggrevates the nerve endings running down under the heal especially since I was weightbearing 10+ hours a day on it from 11 days after surgery. Doc thinks soccer may happen at end of June. Goal is to do one GOOD heal lift by end of next week. PT says once I can do ten one legged we will get to jogging and then Running possibly end of May. I get my ultrasound next Wed as part of the study I am in that will tell us a lot about my tendon length, thickness and healing. I started out fast but feel myself at plateau kind of like when you peak weightlifting at your max bench and then five pound increases are a big step. I will have to work hard to get there but like we all say slow and steady.

  16. Dear Marina

    Great to see that you are back on the court. I noticed from from your earlier blog your concerns about ATR’ing the other foot.

    Like Norm I ruptured my other (right) ankle, but it was the posterior tibial tendon, not the Achilles. And like Norm I think my performance got better, especially in running.

    A bit of caution: About a week before I ATR’d my left ankle, I was feeling an ache on either side of my left knee, when I had my leg out straight, even with no weight on it. I would get relief by bending the knee. I now know the ache was coming from where the two gastroc muscles attach to the femur. After the ATR, the ache was gone.

  17. Is it really true what they say about ROM then? I have heard from some sprinters friends of mine that usually when your ROM is wider than it used to be or your normal one anyway, you do accelerate quicker and you do better and higher jumps. Or is it just a myth? My pt said anyway that my repaired heel will be stronger than previously.
    Thanks for the warning sully, will keep that in mind.

  18. Hi Marina

    Great question. I don’t have an answer.

    In my case, before the right PTT rupture, my left foot was stronger. After PTT recovery, my right was stronger, but with a slightly limited ROM. The repaired tendon is too thick to go through the passage under my ankle bone (medial malleous). I found I could bounce off the right ankle easily at ROM lockup, and gain speed running and accelerating. Sort of like loading a big elastic, and using that stored energy like a slingshot.

    I think that new strength in the right ankle over-taxed the left, so it eventually ATR’d, but after 10 years. PT wants to limit the ATR recovery ankle’s ROM so it matches the PTT (right) ROM.

    I think you probably will have more strength in the recovery foot afterwards, regardless of ROM. I now appreciate the need to keep the other (good) leg toned and stretched, because if it (the good leg) freeloads on that new strength in the other recovery leg, its (the good leg) tendon and calf muscle will weaken.

  19. Sullypa hi,

    I torn my right tendon, this is my good foot. Right now, my left foot is stronger than ever. Maybe stronger than my good foot before rupture. My body has always been pretty flexible and I noticed that jumping on my left leg I can now touch the basket’s net higher than I used to. Dorsiflexion to my repaired leg is limited, maybe 10 degrees less than on good foot, but plantarflexion is appx. 10 degrees more than good foot.

    Yes, I believe it eventually will be stronger than before and that this has nothing to do with ROM. I’ll just have to equally distribute power to both legs soon as healed. But this comes through my head and this is the difficult part, even if I’m not that afraid of it anymore.

  20. Sully, you’ve puzzled me again! Can you help me make the connection between your knee discomfort and your ATR about a week later?

  21. BTW, mikej, you seem well ahead of the curve, with a 75%-normal 1-leg heel raise at 11 weeks. Don’t go nuts, though. (I’ve posted my own cautionary tale in at least a half-dozen places on this site!)

    This stage so many of us are in, feeling pretty good but still short on calf strength, does feel like a “frustrating plateau” (doug53’s phrase), but it does pass, though at variable speed.

  22. Hi Sullypa,

    How do you know when tendon has collagen III and when collagen I? scar vs normal material. I mean inner tendon scar.
    Any test can tell that?
    How to accelerate this process?
    Is it just blood flow that can be accelerated by some and more exercises?
    I don’t have any med background, so plain English and url are very welcome.

  23. Hi Norm

    I’m not a doctor, but think the body presents pain at locations where we have nerves, and not necessarily the source location. For instance, when you tried 1 foot rises 8 yrs ago, you probably tore some AT weak scar tissue (collagen III) fibers and/or calf muscles, but felt pain in the heel, away from the source. Scar tissue has no nerve endings in it.
    In my case, the calf muscle is composed of 3 muscle groups, 2 of which attach to the back of my thigh bone on either side just above the knee. It’s at the attachment points that pain presented.
    In regard to surgery v. non-surgery. I had surgery, but agree with you that in many cases non-surgery is possible. To me the decision rests on whether the final repair state can transition as much of that weaker scar tissue (collagen III) to normal tendon tissue (collagen I) as possible. And whether my lifestyle can tolerate having a possible gap between strong tendon material on each end joined by weaker scar (collagen III) tissue. The tendon at times has to handle pulling forces up to ten (10) times body weight. This is not going to be a problem in normal strength testing, etc. but instead during those accidental yanks from slips, impact from kicks (ourselves and others) and hit by balls, hockey sticks, bats, etc.
    So I’m not going to advocate for either procedure. Responsibility of others’ health is not my bag.

    Hi Mike

    Blood flow is necessary to bring nutrients for collagen I into the AT, and remove the residue from collagen III breakdown. The only way I know to enhance that process is massage, although some PT use ultrasound. I find the massage works. I don’t have any experience with ultrasound.
    I judge the amount of scar tissue by palpatation: when massaging I can feel scar tissue when I squeeze my left ATR tendon between thumb and forefinger and compare it to my right tendon. The closer it is to my right, the less scar tissue. So I spend extra time and pressure on the thicker areas. Learned that at PT. Most of my ATR tendon is very close to the uninjured side.
    Mike, I think your focus on tendon strength, not calf muscle strength, is right on. My concerns are avoiding re-rupture, which is based mainly on tendon strength, not muscle strength. I think the easiest way to build both is to engage in activities you enjoy, but that fire those calf muscles. Exercise in a boot does little to build either. I was PWB/FWB in a cast/boot from day 2, but still had atrophy.
    I now do many of the sports I did before ATR, at 13 weeks post-op. Sunday our softball season began. I played centerfield, hit 3 for 5, and drove in 4 RBIs. Yesterday I played 2 hrs doubles tennis. I (pressure on the toes) walk 1-2 miles a day on the beach.
    Saturday (4/24) I pressed 116 lbs on the bathroom scale. Last night (4/27), after tennis I pressed 136 lbs. I’m not focused or limiting my activites on the single toe rise, but am working toward it. I know it will happen some day.

    PS: I’m 65, like Norm.

    Lou

  24. Mike, I think the short answer to your question is “Check the size (thickness) of your AT.” When our torn ATs first start healing, the tendon is an unnaturally thick mass of not very strong stuff. You can think of it as a fat rope made up of twisted strands of paper.

    As the process advances, that fat rope is replaced with a thinner one, made up of stronger stuff, like nylon or wire rope. And we can see and feel the difference, because our smart bodies know that we don’t need or want a FAT rope made out of that stronger stuff.

    My own PT commented a few weeks ago about how much thinner my AT was than it had been a couple of weeks earlier, and he was pleased with the change. I’m starting to see those two hollow spots above the back of my heel again, as the tendon thins.

    It’s not always easy to spot the difference between tendon thickness and general inflammation in the area, but squeezing the tendon between your fingers can tell you the difference. At first, you want the gap to be filled in with SOMETHING that can handle some tension, and later, you want that “something” replaced with “the good stuff”, which resembles your other leg’s tendon.

    (Mind you, it’s also a sad-but-true fact that we’ve all torn “the good stuff”. . .)

  25. Lou and Norman, thank you for your answers ;-)

    Peteco, sorry for hijacking your post.

  26. Hi Norm. Not sure how the blogs get distributed but check out my first one since the site went down, when you need an attaboy.

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