Rupture and Subsequent Re-rupture

August 13th, otherwise known as Friday the 13th, while vacationing in Costa Rica I slipped and fell while attempting to climb a wet grassy hill.  My right foot lost traction, while my left foot was firmly planted.  As I fell forward, all my weight being transferred to my left foot and ankle, I didn’t hear the normal "pop", rather I heard a tearing sound which seemed to last for seconds, even though I’m sure it was only a fraction of that.  Initially the pain was severe but after ten minutes or so I began to think I could get up and continue on.  Fortunately there were some friends close by and they helped me to my feet.  I knew then something bad had happened.  I could walk flat-footed with little to no pain, but I couldn’t walk normally.  With help I got to the house, got settled, and got on the internet to start my research into the possibilities.  It didn’t take long for me to realize I had ruptured my achilles tendon.  The next morning I visited the emergency room in San Jose only to be told to go home and rest the ankle for a week or so.  I proceeded to tell the emergency room physician (who by his own admission, was just a general practitioner that really didn’t know much about these things) I wanted, at the least, a sonogram to confirm or deny my suspicions.  He agreed, which later led to a visit from an orthopedic surgeon, to explain the results.  The ortho recommended immediate surgery but also said I had the choice of waiting a few days if I preferred.  I opted for the surgery immediately.  Turns out I had torn the tendon at the insertion point and had a bone spur that had to be removed.  The tendon was re-attached with some sutures and two dissolvable bone screws.  The surgery went well, I was placed in a hard cast and sent on my way.  The next day I decided to book my flight back to the US where my wife anxiously awaiting my return.  A blessing in disguise was the fact the cast had to be split to allow me to fly which resulted in a half cast, much more comfortable.  When I returned to the US I visited a local ortho which did a simple inspection and scheduled a visit for two weeks.  At the two week visit he moved my foot to probably five to ten degrees plantarflexion, removed the stitches, and installed a new "half cast".  This was to continue for three weeks and then re-evaluate.  At five weeks total, post op, the cast was removed and I was placed in a rigid Aircast boot with my foot at neutral.  I began immediate weight bearing and was very comfortable with my strenght and balance.  I have to admit, I had been taking my foot out of the half cast and moving it around gently during the last few weeks.  After a few days I began to walk around the house without the boot, then into tennis shoes, with no problems except a slight limp, and even that was going away quickly.  At about two weeks after coming out of the final cast I was feeling pretty good, then the dreaded, "fall forward" happened.   It was just over seven weeks post op when I was in my house, bending over to pick something up, balancing myself with a hand on a bookshelf, and the bookshelp gave way.  I fell forward, felt the "pop" this time and the initial pain, knew what I had done, and immediately experienced an all time emotional low.  Obtained an MRI (which, by the way, aren’t always that conclusive) and was sent to what was billed as the best foot and ankle ortho in my area.  He evaluated the MRI, told me I had a rupture, inspected my original incision, and wasn’t hesitant to even discuss opening up my original incision.  Turns out he was already treating a patient with an achilles rupture that had developed a deep infection, and in his words, "we’re fighting to save her leg at the moment".  He told me to come back in one week to discuss my options.  I returned in one week only to be advised by him to not have surgery and go the non-surgical route.  His only reasoning was the chance of infection concerned him.  Long story short, I opted for surgery because of a re-rupture and the possible associated unknowns.

Re-rupture surgery was performed one week after injury and all went exceptionally well.  Ortho said there were no problems, no signs of infection, stitched the tendon back together using the "Krackow" technique, and the tendon looked healthy.  Turns out the re-rupture was in the more normal location, several centimeters above the insertion point.  I was at least glad to know the original repair was holding well.  Two weeks in a full cast at which point stitches were removed and a new, very tight, full cast was installed, both of which were at twenty degrees plantarflexion.  This second cast was to remain for four weeks and it was a tight fitting, uncomfortable one.  By his own admission the ortho was treating me more conservatively than normal because of my re-rupture history.  At six week post op the cast was removed and I went into a hinged boot, again at twenty degrees.  I was a little disappointed at this but had done my research so began a little therapy on own shortly thereafter.  Just simple movement with PWB, no stress and after two of the four weeks I began to slowly move the boot to neutral and move to FWB.  At the six week post op visit I was at neutral, FWB, and progressing.  Ortho said to wear the boot a few more weeks, for the most part, then progress into shoes and walking carefully.

I’m now at eleven weeks re-rupture post op, performing my own therapy, and seeing steady progress.  Nothing against seeing someone for therapy but I’ve done my research since I’ve had double the time most have, and I have a friend that is a physical therapist that visited my and gave me many pointers and suggestions.  My only problems seem to be associated with the extended time, including the degradation of my calf muscle, and the stiffness in my foot and ankle.  Even at that I am seeing slow but steady improvement.  Last but not least, at my last ortho appointment, my doctor looked at me, smiled, and said "I think you made the right choice", in referring to me going against his recommendation and electing for surgery.  He made my day.

Sorry for the extra long post, it’s mostly a result of condensing almost five months of injury and treatment into my first post.  It is very nice to have a site such as this to visit for advice, information, and to just read about others experiences.

2 Responses to “Rupture and Subsequent Re-rupture”

  1. Hi, this is a comment.
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  2. The only part that rings false to me is “By his own admission the ortho was treating me more conservatively than normal because of my re-rupture history.”

    This knee-jerk is very common, but every attempt to back it up with evidence fails miserably. Holding a patient back longer in a cast makes the Doc feel better, and may even make the patient feel better, but it does NOT seem to decrease the risk of re-rupture. If anything, it seems to do the opposite. Facts are funny that way.

    Your first rehab was going well, when you made a risky bet, betting on a piece of furniture that wasn’t worth the bet. Bad luck, but bad stuff happens. It wasn’t your whole rehab schedule that was at fault, it was just one unfortunate move — a move that almost didn’t happen. Lots of us had similar “near misses”, and only a few of us actually re-rupture.

    The fact that your AT tore in a new (and conventional) location suggests to me that a good modern non-op protocol might have worked just as well as surgery. We’ll never know, and we’ll probably never even have a good study to guide our guesses. But this is all academic now, and surgery usually works well, too, so you should recover well with a reasonable rehab protocol now (NOT a silly slow one!), and a lot of prudence and caution.

    Especially when you lose the protection of your boot or cast, between 8-ish and 12-ish weeks post-whatever, your AT is very vulnerable, and you must constantly Watch Your Step — as you now know by tragic experience. But adding extra immobilization or extra time NWB (at least compared to a good tested protocol like the one at bit.ly/UWOProtocol ) seems to do more harm than good, so avoid that trap.

    Good Luck, and Good Healing!

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