Feb 21 2010
2 Year update
Hello All,
Coming up on my 2 year anniversary. What a journey. Life is back to normal, no second thoughts when running, jumping, or biking. Back on the court full time, and actually beat the guy I had to forfeit to when I blew my AT. Racquetball going full time with no apprehensions to playing. So to my fellow ATR brethren…do your PT, push when you need to and you will be back to what you love to do in no time.
Take care
Doc Ross
Great to hear this Doc Ross.
I see your previous post at 7 months still had weak calf muscles. How long did it take to get the full calf strength back? What were the most useful exercises for that?
I am kind of tired of calf raises… Still have a 3cm difference in calf size after 7 months.
A cheeky question: did you do the planned triathlon on your ATR anniversary?
2ndtimer,
No I did not do the triathlon on my anniversary but did get to play in a racquetball tournament. Actually just signed up for 2 adventure races this spring and summer. Calf is still smaller by 2.5 cm even after 2 years and thousands of calf raises. Just make sure you are doing them seated, standing and with your toe-in, straight and toe-out.
Talked with several other veteran ATRs and all have some varying degree of size loss. My understanding is that the normal achilles tendon actually twists slightly upon inserting into the calcaneus and this helps tensile strength and therefore girth. Unfortunately it cannot be surgically duplicated which leads to size, strength and endurance loss. So my friends, recognize you will never be the same…….however surgically implanted calf inserts…..LOL….
You will get there….persistence
Doc Ross
Hmmmm…. I am really disappointed to hear that the size did not come back. Well I will continue wearing mostly pants. No implants, do not wish to go under the knife again!
My PT told me to do as many calf raises as I can - but that is sort of impossible. How much is reasonable per day?
I can do 20 on one leg comfortably, then switch to 2 legs, or rest, then do more. But it is BORING. And it tires my forefoot. I have not done seated ones since I graduated to standing ones, but maybe it is useful to keep moving even while sitting.
I heard someone mention some sort of lubricant around the tendon - could that be that we have a deficiency of it since surgery and that is why we feel stiff if not moving for a while and why I actually prefer to circle and move my feet even when sitting?
For what it is worth, my calf is same size and same strength (both measured carefully) as the other since six months postop, so I would not say it is inevitable. I didn’t have the long period of enforced immobilization in a cast like most, however, and that could be a key difference. It may be prolonged atrophy, and not the injury itself, that is to blame when full size and strength never return.
If you are sick of calf raises, walk around up on your toes all you can, and “bounce” it more when you are able, especially when going down stairs.
If you can, jump up and down on your injured leg, keeping your heel off the ground. There are ways to load the calf more than single-leg calf raises.
Best wishes,
Doug
Another more extreme version of calf raises (single or double leg) is to do them on a stair or a stepstool, with your heel hanging out over nothing. Then you can drop down below neutral, too, and get a heel lift and lower, both with full ROM. (My sis did a bunch of those when she was a pretty and vain young thing, and wanted cuter calves!)
BTW, I’ve only put a tape on my calves once since the ATR (maybe around week 6?). To my surprise, they both measured exactly the same circumference at their biggest points! But they still look quite different — and act quite differently, of course! The “bad” calf has much less projection toward the other leg (medial?) than the good one. Since it’s the same circumference, it must be projecting farther to the rear(!).
After 10 weeks, I can now just do balanced 2-legged calf raises, and I can just sort of walk perfectly, when I remember to do it! (When I first get up out of a chair, I tend to limp.)
Surprisingly, my ROM seems identical on both ankles, too! Mind you, my “good” ankle lost some dorsiflexion from its ATR surgery 8 years ago, so I don’t have a “perfect” ankle to compare to. I don’t remember if I ever measured my calves after I returned to serious sports — but they looked very similar before this ATR.
Just Started doing light Calf raises and not very high at all. My other AT on the left leg will be going under the knife in August, so my calfs and ankles will look the same when I’m all done.
I too limp when i get up from a chair, but it slowly goes away once I have been walking for a little bit.
THANKS for the update…if give me hope!
Ross - Great to hear from you again. It sounds like you’ve put the ATR behind you for good. Way to get your revenge on the court. Thanks Doc!
Doc Ross - Congrats, and thanks for the update. Please post the picture of your Achilles tattoo.
I might get one as well.
Well Done Doc Ross,
I’m coming up to my 2 year anniversary as well in March, can’t believe how time flies. I’m still slowly recovering, no calf muscle yet, but have had a fantastic new physio who has made all the difference.
Keep up the good work.
Annie
Another way to add more work to single-leg calf raises is to add “weight” by using your hands. Perhaps the most available example would be to stand in a doorway and push hard up against the top of the doorway with both hands while doing calf raises. Pulling up on a sturdy railing can do the same thing. There are many homemade ways to maximize the benefit of your exercises; look around and use your imagination.
Doug
Hey Doc,
My name is Joe and I ruptured my achilles on 9/8 of this past year. I underwent surgery on 9/11 and am now looking forward to my sixth month mark, but also a bit confused about it, so I thought I would ask your opinion. The last appointment I had with my doc was in November and he told me that I no longer needed to see him and that I could return to all of my normal activities on 3/17/10. So, I have not been allowed to play sports or jog (I have been extremely bored). I guess my question is this, how solid will the tendon be and should I worry about a re-rupture? I am 28 years old, and prior to this injury I was a very active runner and played competative hockey and racquetball. If I return to these things, am I running a huge risk of another injury. FOr instance, there is a 10K that I would love to run on 3/20. I have been working out on an arc trainer and have found that I can push myself pretty hard without much fatigue or soreness in my ankle. I can also do single leg heel raises till the cows come home. I feel like I am in good enough shape to run the 10K, but I don’t know if it is crazy to try. What do you think, am I nuts to want to run this race? I am not worried about hurting my ego, I am only worried about my tendon.
Thanks in advance,
Joe
Also, are there any supports or braces you would recommend incorporating into my return to these activities?
Thanks again,
Joe
jose, my surgeon told me that I have better chances to rupture my other AT than the repared one. He is a confident guy… If you feel so good I do not see why you could not do all these activities. Just do it gradually and listen your body.
Jose,
I think your tendon is stronger than any support stocking.
If you have not run yet since surgery, going for a 10K race in 3 weeks might be too much too soon. I think you should take things more gradually.
After I tore my first AT and had surgery on it, my surgeon — he called himself “conservative” and he was right! — told me I could go back to competitive volleyball when I could do a bunch of single leg heel raises without grunting or sweating.
That’s what I did, and I decided very soon that (a) my heeled AT was the one part of my body that I had the MOST confidence in, and that (b) my other AT was the one I was most nervous about. About 7 years after that (and 8 yrs after the first rupture), I did actually tear the other one, and it’s maybe half-way back to grunt-free single leg heel raises. Not a hint of regret here, given how much satisfaction and fun I got from 7 years of volleyball.
I don’t think I could EVER “do single leg heel raises till the cows come home”, so you sure sound ready to me!
I’m sure I was nervous and maybe tentative when I first returned to the volleyball court, but that passed very quickly. I’ve never been a “real” runner, so I can’t advise you on which race, how soon, but I’d say “Get going!”
BTW, I didn’t use any braces or supports, and most people here don’t recommend them. Some people find the back of the shoe rubs and irritates the healed AT a bit, and your heel might need some extra padding but that’s probably the only two new problems I’d even think about accommodating. Listen to your body.
Jose,
sounds like you are doing well. It takes a full year for the tissue to recover. Your body is laying down connective tissue that will take 10-14 months to become fully repaired. Obviously it also depends on the degree of tear, type of surgery and your adherence to PTY. I did the Grand Canyon 10 mile hike, rafting and climbing at about 3 months. I would go slow with your race, your not nuts just ready to break free from this pain in the ass injury. Do not try to push it, no PRs yet.
I wore an ankle support up until 1 year and have not worn one since. Once you get your confidence back regarding your body you will not need it. There are pros and cons to bracing but I have found it depends on the person and their athletic endeavors.
Hope this helps. Make sure you are getting massaged regularly, definitely helps with healing, work out recovery, blood flow and just plain ol feels good.
Good Luck
Doc Ross
Has anybody else heard this? My Doc said that my achilles will be at it’s weakest point 6 weeks post op. It seems it would be at it’s weakest point right after surgery. Any ideas?
At least one other person on this blog related hearing this odd statement. I’ve done quite a lot of reading and never run across anything to back up this statement, though.
FWIW, I was putting 140 pounds of pressure on the toes of my injured foot at six weeks. I very strongly suspect that would have been a Really Bad Idea right after surgery.
Next time you see him, maybe he could provide you with a medical study reference that backs this up.
Puzzled right along with you,
Doug
Here are my .02 on this.. ATR surgery usually use absorbable stitches. All sutures are classified as either absorbable or non-absorbable depending on whether the body will naturally degrade and absorb the suture material over time. Absorbable suture materials include the original catgut as well as the newer synthetics polyglycolic acid (Biovek), polylactic acid, polydioxanone, and caprolactone. They are broken down by various processes including hydrolysis (polyglycolic acid) and proteolytic enzymatic degradation. Depending on the material, the process can be from ten days to eight weeks. They are used in patients who cannot return for suture removal, or in internal body tissues. In both cases, they will hold the body tissues together long enough to allow healing, but will disintegrate so that they do not leave foreign material or require further procedures. Occasionally, absorbable sutures can cause inflammation and be rejected by the body rather than absorbed. This along with the healing timeframe of tendons there is a vulnerability at the 6-8 week mark. This is when scar tissue is laying down its matrix for strength. Also at this time is when ROM exercises are a must.
Again more of my professional opinion than based on research.
Hope this helps…
Doc Ross
Doc Ross:
I can imagine that if inflammation from rejected suture material is severe enough, it could lead to significant tendon weakness. I suspect that isn’t a common problem, however. Does anyone remember anyone in this community of several hundred ATR victims who reruptured because of rejected sutures?
Assuming the sutures are absorbed in a relatively normal fashion, my reading indicates that there are three phases to the healing of a ruptured tendon. First, the inflammatory phase generally lasts a small number of days, when the wound is “cleaned up” by various white blood cells, (and it hurts a lot, as inflammation does, basically by definition). Second, the proliferative phase, when lots of collagen is laid down, lasts a month or so. Around six weeks out, the third phase, remodeling, starts, and lasts about a year, and the tendon becomes about as normal as it ever will.
I read about this in a review article in the Journal of Bone and Joint Surgery, 2005, 87:187-202.
If most of the collagen is put in place between roughly one to six weeks postop, I don’t see how that means the tendon should have a weak interval at six weeks out. Being pessimistic, I wonder if there are some doctors who tell their patients this to scare them into compliance with their conservative rehab programs.
Ever the skeptic,
Doug
Doc Ross!
The man the myth returns.
I used to look forward to your blog updates..back in the days of tedious recovery.
Great to hear you’re doing well…was in Vegas playing in a Pro-Am last November..thoughts of the ATR Open were dancing in my head..oh the missed opportunities..
Walshie..
How goes it?? Golf game better or worse?? Actually won VA state 45+ singles racquetball tournament, ranked #1 in VA…
Now I’m ready for some golf…
How are you?? any problems??
Doc Ross
Hi Doc Ross,
Congratulations on passing your 2 year anniversary!! I am coming to my 2 year anniversary after rupturing my AT during a basketball game after almost shutting out my opponent in the 2 previous games (Did I really need to play the 3rd game?). I did my PT for 6 months (not intensive) and I now play basketball here and there but I still don’t have nearly the strength or confidence as I did before. It also still feels a bit tight and sore. Do you know if this is a normal occurrence for someone who has not finished his PT? is the leg lifts the answers? Are squats and leg presses bad for the AT? An osteopath also recommended messages for the scar tissue. Is there still hope after 2 years? I will still consult my physician but he has not gone through his so I would like to hear from you. Whatever advice you can give will be appreciated. Shame I did not read your blog before today.
Kind regards,
Oren
Ross:
I injured my AT playing racquetball this week. I just had surgery today. Your blog post really gives me hope that I’ll be back in action at the same level as before within a couple of years. Thanks for the post!
Ben,
Sorry to hear that. Read the blogs, stay motivated, definitely sucks but you will get thru this. Happy to say that I am now number 1 in the state of Virginia in my age group and one of the top players in the state. I have no residuals other than the scar and my vertical went from 6 inches down to 4….LOL.
Let me know if you have any questions and good luck.
Doc Ross
Hey Doc Ross,
Glad to hear that you are completely recovered! I ruptured my left achilles 2 days before I started practice as a brand new PA. I just had surgery and will be back in the office in a few days. Just wondering if you had any hints for examining patients while on crutches or a scooter. I had a few days before surgery of seeing patients and found it extremely difficult.
Thanks!
Moll,
Sorry but no hints. I would scoot around the office and when I had a moment I would sit at the desk with my feet up. Actually had fun wheeling around and enjoyed all the comments from patients. However by the end of the day I was exhausted. Be careful no to overdo it.
Good luck
Doc Ross