ATR in the UK - week 8, day 2: Physio & wedge removal

I had my first session with the physio last week, and finally feel I’ve started to make real progress with my recovery.  The appointment was 6 weeks post injury and I’d been in the boot 5 weeks, so it was a bit overdue but the earliest they had due to the length of their waiting lists.

I was met by a male student who didn’t look anything like the Specialist Physio Rochelle I’d been told I would be treated by, which concerned me slightly, but once he’d finished taking my history she arrived and supervised while he assessed my range of movement and then did some basic manipulation.  We were all pleasantly surprised by the range of movement I had, as I was able to achieve plantigrade with only a little assistance, and inversion/eversion were almost the same as for my good foot, and I was able to give plenty of resistance to pressure when needed.

Based on that, the upper of the 3 wedges and the shallow heel cup were removed from the boot, and I was given what I imagine is the standard exercise to do 5 - 6 times a day: with my leg straight use a towel to pull back the ball of my foot until I feel the pull in the tendon/ muscle and hold for 30 seconds, then repeat.  I was also told to ditch the crutches and go full weight bearing unless I need to go a long way outdoors, and booked another appointment for 2 weeks later for further wedge removal.  However after I got home Rochelle phoned to say that if I didn’t have any reaction to removal of the wedges after  4 - 5 days I could remove the next wedge myself at home, and the last one would come out on my next visit to get me back onto the schedule they’d normally aim for.

I had no reaction so duly removed the second wedge on Saturday, and again have had no reaction since, though I did find that without the heel cup there’s a lot of space in the bottom of the boot, and my foot was sliding around quite a bit which could make the boot uncomfortable as a result.  I’ve therefore put the heel cup back in which has been a definite improvement even if my foot is slightly more plantiflexed, but I don’t think this will be a problem since after a week of the stretching exercises I can now achieve a few degrees of dorsiflexion without help.  My whole foot and ankle feel a lot stronger, and the swelling on my foot has also almost disappeared of its own accord which is a nice bonus.  The swelling above my ankle reduced slightly by itself, but adding extra padding inside the boot to increase pressure in this area has been really effective to the extent that when I take the boot off my injured leg is almost the same shape as the good one.

Getting around without the crutches is made a lot easier by the Evenup, and I have the stamina to do the school run on crutches Ok, though if I’m running late it does leave me puffing a bit, which I guess is no bad thing.  My cough has reduced to the extent that I’ve started some core & upper body exercises, and I’m going to have a look at some of the other exercises on Evan’s videos this week.  Overall I’m mostly feeling a lot more positive now, but I can always find something to worry about, which is now how difficult it’ll be when the boot comes off.  I’m expecting the last wedge to come out at my appointment next Tuesday, and to be in the boot at plantigrade for a week or maybe two before I’m back to shoes - does that sound about right to those of you who are now back in two shoes?  The other thing I’m wondering is how I’m ever going to get the full range of movement back in that ankle: I can achieve about 25 degrees of dorsiflexion with my good foot and at the moment that just doesn’t seem likely to be possible on the injured side, but I guess I just have to stick to the exercises & keep thinking positive!  Hopefully another update more promptly after next week’s appointment.

ATR in the UK - Week 6, day 5:Swelling, Even-up, and 1st physio next week.

Well my good intentions about exercise were immediately torpedoed by a nasty chest cold which my daughters brought home from school, which meant that anything which made me breathe more heavily than normal resulted in a spell of jackhammer coughing leaving me with streaming eyes and in need of a sit-down - thanks girls.  Feeling a bit better now, but it’s taking its time.

As a result, my mind has turned to the swelling which after a couple of weeks in the boot was still present around my lower calf and foot and has persisted since.  This seems to be oedema rather than bruising; on the outside and top of my foot it’s quite soft and can be pressed or massaged away to a large extent, but above my ankle it’s a lot more firm and doesn’t easily disperse when pressed.  I’m pretty sure it occurs in these areas because the boot doesn’t apply any pressure here: the side/ top of my foot is where the gap is in the foam liner, and either side of my lower calf the boot is too wide to apply pressure even with the airbags pumped up quite hard.  From what others have written here I don’t think the physio will be too impressed that I haven’t tried to tackle this, so I’m going to try adding some extra pads inside the liner to apply pressure to my calf & see what effect that has.

On the bright side Morcs’ Evenup arrived last week, and it’s definitely proving helpful around the house and out & about.  Wearing it on a running shoe makes that leg only about half an inch shorter than the booted leg, which makes it a lot easier to bear weight on the injured leg in a controlled way, and seems to be easing the pressure on my left hip as well.  I crutched to the doctors earlier today about an unrelated issue, about 900m almost non-stop, and it was a lot easier than long distances had been before, which bodes well for getting back to doing the school run.  My wife has been picking up a lot of slack since the injury, including 4 school runs a week which has meant that she’s been unable to take up an offer of more hours at work.  Her employer is now saying that she has to start the longer hours from the end of this month when her current contract expires, and the only way she can do this at present is spreading them over 4 days instead of 3, which we really don’t want because of the pressure it puts on other aspects of domestic life.  Another parent’s husband suffered ATR and said that it had put a real strain on home life especially as he was self-employed like me, and I’d be interested to hear what other people’s experience has been of this aspect.

My referral to the local physiotherapy unit was rejected because apparently my post-op care was "purchased" as part of a surgical care package.  As I haven’t had surgery I can only take this to mean that once I’d seen the consultant at the hospital there was no other option due to the local NHS Trust structure and charging systems - so much for patient choice!  By coincidence the doctor I saw earlier ruptured her AT a couple of years ago, and she suggested that this might mean that the local unit don’t see many ATR patients so I’d be better off at the hospital where this is more common, and in this case I’ll take experience over convenience every time.

Luckily I’d booked a session with the hospital physio anyway which is next Tuesday, and I’m really looking forward to getting some feedback on how I’m healing and some exercises etc.  I’m also hoping they’ll remove the first wedge given that I’ll have been in the boot for 5 weeks by then, though still slightly nervous about what that will mean in terms of pain for the first few days afterwards, so any advice on that or anything else to expect would be greatly appreciated - I’ll let you know how it goes!

ATR in the UK - R+30: Exercise in a boot

So, it’s the 2nd day since the local physio unit told me they’d call in 1 - 2 days to fix my first appointment and still nothing; will chase it tomorrow if I don’t hear by the end of today.

In the mean time I’ve been musing on how much of my core fitness I’m going to lose because of this.  It looks as if my right thigh & calf are starting to become smaller; they were a lot stronger and probably a bit larger than my left before this happened so ironically I might eventually be better balanced as a result of the ATR in the end, but I haven’t measured them yet, might find it a bit depressing.  I crutched about 1100m up to the shops & back at lunchtime, about 500m non-stop, which got me breathing a bit, but it’s not the same as pace drills at my martial arts class or a long bike ride, so my aerobic fitness is also going to go a long way down the tubes if I don’t do something.  So, I’ve set myself a couple of tasks/ goals:

  • I’m going to do some crutching every day (weather permitting) and try to build up my stamina to see if I can start doing the school run again on crutches - 900m each way with a slight hill on the way.  My wife would be very pleased about this!
  • Sit-ups, press-ups and planks are all possible in the boot without putting any tension on my calf, so I’m going to start doing some of those daily to make up for what I’m missing at martial arts & may help with the crutching.
  • I saw on Evan’s blog video that he set his bike up on a turbo-trainer and was able to do some cycling in the boot once he’d fitted a flat pedal on that side.  I don’t have a trainer at the moment, but am going to look into the cost, as it’ll be a good few months before I can cycle on the road again.

I’m not giving anything up for lent, so hopefully this’ll stop me gaining too much weight as well, I’ll let you know.

ATR in The UK R+28 - Creeping closer to physio

Just a quick update on my journey through the NHS’s referral process.  On Saturday I got a letter from my surgery confirming that I’d been referred to the local physio unit; goody I thought, as I’d heard you can book appointments online.  Er no, not in this case.  I had to phone up, which I did this morning, expecting to be able to book an appointment.  Wrong again.  After giving my reference number and password, I was registered onto their system, asked what part of the body I needed treatment for, then told my case would be triaged by a clinician and I’d then get a call back to arrange an appointment within 5 - 10 working days.  At that point I might have lost the plot if the lady hadn’t quickly told me that it would actually be 1 or 2 days as they’re processing very quickly at present, which I hope is a good sign for an early-ish appointment date.

But honestly: wouldn’t it be possible for the GP to send the details of the diagnosis and treatment recommendation from the consultant to this unit at the time of referral so that they have the information and can assess it before I phone up and an appointment can be made there & then?  I can only put this down to the vagaries of the NHS internal market structure, plus the difficulty of successfully changing a system this complex - the record of big IT projects in the NHS isn’t that great I believe.

Not much change with my leg, other than everything feels a little bit more robust than it did, and based on comments from a few people plus browsing some other blogs, when I’ve got the boot off I’ve started gently massaging the swollen areas away from the injury site to try to reduce the swelling, and very gently flexing my ankle - plantar and dorsal, plus eversion & inversion, just to keep it mobile, but no stretching Morcs, honest!  More news soon I hope.

ATR in the UK - Living with an Aircast boot

Hi - this is my first real blog post, though I have posted one or two comments on the site before.  If you haven’t see those, as a bit of background, I’m 52 and live near Southampton in the UK.  I’m pretty active, playing badminton weekly, doing martial arts twice a week & cycling 30 miles every couple of weeks, but on 30th January I suffered a complete ATR while playing badminton.  I guessed what had happened immediately as one of the guys I play with also had ATR about 20 years ago, though as I could still move my foot a little I thought it might just be a partial tear. I went to A&E (ER) that evening & got a half leg cast with my foot at about 30 degrees, an appointment with a consultant 8 days later, and advice to hang the leg up & behind when using the crutches. I’m not good at sitting doing nothing so after the first 24 hours I was up & doing what I could around the house on 2 crutches or 1 crutch & a stick, & managed to do a 400 yard circuit to the shops once, though found it pretty tiring. All Non Weight Bearing other than the very slightest sometimes needed to maintain balance e.g. taking a leak!

I saw the consultant on R+8, and an ultrasound showed it to be a complete tear in the musculotendinal area with a 3cm gap.  The consultant said this wasn’t appropriate for surgery, so the non-surgical path was agreed and I was prescribed an Aircast boot with 3 wedges giving about 20 degrees of flexion, which I was fitted with the day after.  I was referred to physiotherapy, who the consultant said would remove a wedge every 2 weeks, which I assumed would start 2 weeks after I saw him, i.e. R+22.

I was fitted with the boot the day after (R+9) & didn’t get much advice on using it with crutches, but found it was a lot easier to get around in than the cast was. As a result I stopped just hanging my leg when using the crutches, instead putting my injured foot forward with the crutches and putting a very light load on it so creating a partial walking motion, and with a bit more load on the injured leg around the house using 1 crutch on the injured side only.  It’s also a lot easier to stand without crutches (taking a leak, making breakfast) though almost all of the weight is on my good leg.

Perhaps as a result of being more active I seemed to get more swelling in my calf and ankle in the first couple of days with the boot than when I was in the cast, especially late afternoon and evening, to the extent that it became uncomfortable and there was a bulge above the top of the boot and either side of the elastic of my sock when I took the boot off.  I started taking it a bit easier & elevated my leg more for a while, but it didn’t last because as I said I’m not good at sitting around.  Also my wife’s having to do a lot of stuff I’d normally do, particularly running the kids to clubs etc, so I’m trying to do what I can around the house - sweeping and using the vacuum are both perfectly feasible, and I’ve been able to do a bit of light gardening as well.  The swelling did decline after a couple of days, but the lower calf, ankle and instep are all still a bit swollen; keeping the boot fairly tight when I’m up and around seems to help.  I’m keeping it on at night because I’m worried that it would be very easy to change position in the night and do myself some damage, but I do slacken off the Velcro straps and the fleece liner a bit.  Something I didn’t enjoy was when getting up in the  morning there was an uncomfortable feeling of swelling in my calf & foot, as if blood or other fluid was gradually flowing down as my leg became vertical; again tightening up the boot before getting up seems to help with this, but it still happens a bit.

This is where my learning curve about NHS services began.  By last Thursday (R+17) I hadn’t heard about the physio, so called them instead, to find that it had taken a week for the referral from the consultant to reach them, nothing had been scheduled, and the earliest they could see me at the hospital was 14th March (R+43).  As there is another physio unit much closer to where I live, I asked if they could give me an appointment there, but that one is run by a different NHS Trust, and to get a referral there I’d have to speak to my GP.  I called the local unit to check that was correct; it was & at that time they were booking for March 6th (R+35).  I then called my surgery, but had missed my doc that day, and he was off the next day, but they said to phone the following Monday (R+21)  for a telephone consultation.  This I did, only to be told that they hadn’t received a letter from the consultant about my diagnosis & treatment (even though I’d received it the week before) and without it the doc couldn’t talk to me.  So, I took a copy of the letter in to the surgery & the doc called me later that day to confirm that yes he would refer me to the local unit.  I only go into this level of detail to illustrate what I’ve learnt about treatment on the NHS:

1) It’s brilliant at critical care, but once you’re beyond that point things grind rather slowly.   2) Communication is really slow & a bit unreliable (do they really have to use letters, isn’t there an intranet?)  3) The structure means that it’s not as joined up as you might think.  If you’ve had non-critical treatment with the NHS you’ll know all this, but I’m fortunate to have been pretty healthy so if like me you lack the experience, my advice is: a) Don’t wait for things to happen, chase them up but be nice, they’re very busy),  b) If you have private health insurance then use it, you’ll probably get earlier treatment, and   c) Use the info on AchillesBlog to find out what your options are so you can have informed discussions with the staff.  It’s been 4 days since I spoke to my doc and I’ve heard nothing, so I’ll be speaking to the local physio unit on Monday.

Back to the Aircast boot & some random practicalities.

  • I cut the elastic tops off the socks I’m wearing, which has made them easier to put on and may have helped to reduce the swelling in my calf.  I can take a bath with the boot on, resting my leg on the side, and give my foot a sponge bath every day.
  • If I’m honest the fleece inner of the boot is becoming a bit whiffy even though I’m sprinkling it with talcum powder every day, so it’s going to have to go in the wash on a day when I can put my foot up for a couple of hours while it dries.
  • The Velcro on the straps is the noisiest I’ve ever come across, so if your partner’s gone to sleep before you go to bed, slacken them off in another room first!
  • It is possible to carry a hot drink in your free hand while using one crutch if you cover it with cling film, but take it off asap before it welds itself to the cup!
  • The air bags in the boot seem to lose pressure even if you close the valve; check them every coupled of hours.

In the last couple of days I’ve started to feel the need to stretch my injured leg when I wake up, which I’m resisting, but I hope is a sign that there is now some sort of connection between the muscle and the tendon again.  There’s also a slight pull when I - very carefully - raise my foot beyond the angle it’s got used to in the boot, which maybe confirms this.  I’ve read on here that if the tendon heals too long it’ll be less strong, so hopefully if the delay in getting physio means that it heals a little short due to being longer in its current position before the first wedge comes out than that’ll be a good thing, even if I have to work harder at the physio to stretch it.  I’ll post again once I hear about the physio appointment.  Cheers for now,  Richard.