Ryan Border’s Achilles Blog

I took this picture last night (13wks).

I ski’d reasonably hard on Sunday. Wore my Sketcher Shape-Up’s all day Monday. And then, went speedskating. I quit skating early, because I was getting sore, and seemed incapable of doing much. This is what I saw when I took my skate off.

I’m not concerned; I just thought it looked kind of funny/ridiculous. Keep in mind, the (rigid carbon) skate was custom built around a mold of my non-injured foot, so it’s very effective at squeezing any extra fluid up and out of the area.

Another video that’s mostly for friends and family, but again, it’s a good snapshot of my progress at 13weeks. I took the family skiing today. I’m in the yellow and blue coat. If I’m not in the video, then that’s my shadow with the camera on my helmet

It’s been 5 days since my injury “popped” while attempting a single heel raise. I’ve been trying to figure out if I re-injured it, or did something more benign, such as breaking up scar tissue.

This evening, I gave it the ultimate test- and got back on the skates. The improvement since my last session was remarkable- not only was my range of motion better, but the limit was much more approachable. Before, when I reached my dorsi-flexion limit, it was very abrupt and severe- I’d recoil/reflex away from it, leading to general instability. I’m still “tight”, my passive ROM is still limited, but I can ease up to that limit on each stride, and feel much more in control as I approach it. I was actually able to open up the throttles a little bit, and skate a few mid-tempo laps.

No ill effects from yesterday’s skiing. Walking and spin bike both feel better, due to much reduced ankle pronation. I would say my pain level is back to “pre-pop” levels. It’s a little high right now, but after skiing and skating, it’s about what I would expect.

I have a PT session tomorrow, where I’m sure we’ll do further evaluation- but right now I’m 95% convinced the “pop” was a good thing (even though it scared the hell out of me).

I drafted this just before the “Pop” earlier this week.     With a little time to reflect, I’m not sure anything’s really changed-

By all accounts, I’m entering a new phase of recovery; time to start focusing more on strength and flexibility. I have been waiting for this milestone, and the plan now is to get a little more aggressive.

Statistically, my chances of a re-rupture are dropping. Re-ruptures seem to be most common in the 3rd month (weeks 8-12). I believe there are a few contributing factors. First, there is good evidence that up until 12 weeks, the tendon is still forming and maturing collagen tissue, leaving it vulnerable. Second, looking at the marathon stats, on average, most people move to two shoes at 8 or 9 weeks. It’s not at all surprising to me that the first month in two shoes - as we relearn how to walk - would be the most dangerous. I suspect stacking those two factors together may be largely to blame. In addition to the re-ruptures we’ve been reading about here at AchillesBlog, I know of at least three others in the last month. I became a bit paranoid about it which, all in all, may not have been such a bad thing.

I still worry about healing long but my tendon length is probably set: it is what it is. My indicators are all over the map: plantar flexion strength - especially towards the end of the push - is very weak (too long?), passive dorsi flexion is limited (too short?), active dorsi flexion is normal (just right?).

In terms of collagen formation, I think I’ve got everything working in my favor: relatively young, fit, non-smoking, etc. I had my surgery within 48 hours of the injury. My high level of post surgery activity (I think) should be beneficial. The nutrition program I’ve been on may even be helping. There’s no way to know for sure of course, but I hope (must now trust) that at 12 weeks, my tendon is as well prepared for the next phase as it can be. I’ve also been in 2 shoes for almost 7 weeks now and have regained fairly good stability. I think I’m probably through the worst period of associated risk. I will of course continue to exercise due caution, but it is probably time to start trying to lose some of my paranoia.

Measurable progress has not seen drastic changes. Still no single leg heel raises… (Ha! I deleted the rest of this paragraph, it’s the one thing that did change, and all the gory details are in my last post)

I’ve continued the (back-country) skiing without any problems. The resort I usually ski at (Snowbird ) is opening up, and I’m about to discover how my Achilles handles extended downhill. During a back-country day, I spend ~80% of my time climbing, and I’m lucky to get a couple of downhill runs in. For better or worse, I expect resort skiing will be very different. In an act of blatant optimism, I bought a season pass back in September - and hope to ski 40 to 50 days this season.

I’ve been skating a couple of times a week. It’s still the most challenging activity for me, relative to the injury. My form is improving, but my endurance and power are still poor. My limited flexibility (passive dorsi flexion) is proving - as expected - to be a very serious limitation on the ice, which just means I have good motivation to work on it. The Masters National Championships are in January (in Milwaukee), and with my optimist hat on, I’m starting to think about using that as a medium/long term goal to shoot for. A stretch goal, so to speak

I’ve been making good progress towards the dreaded single heel raise. It was a topic for my 12 week update I’d planned to post tomorrow.

I’ve been doing assisted heel raises at the gym. Basically, I stand in front of a "pull down cable", grasp the bar underhanded, and pull it down to my chin- as if I was doing a pull-up. Then, I’ll stand with my toes on some sort of a block (typically, a 25lb weight), and do the single leg heel raises. The weight in my hands works as assistance- I started out with 100lbs. I’ve been doing 3-5 sets of 10, through a good range of motion.

I’ve also been working on the stairs. When ascending, I’ve been trying to keep my heel off (but safely over) the tread. When I started out, I would inevitably "fail"- with the heel touching at the end of each push-off. But, over the last week, I’ve started to be more and more successful; reaching the point where I could climb a whole flight of stairs without my heel touching. I even got a bit brave, and have climbed a few flights normally , with my heel hanging off the edge of the stair.

Another thing I’ve been working on is statically holding my weight in a heel raised position. I’ll do a double heel raise with a fairly wide stance, weight biased to my strong leg. Then, I’ll laterally shift my weight onto the weak leg; until it fails; until I feel the heel start to drop, or my confidence/pain level says to stop. I reached the point where I don’t have to stop: I could stand there - briefly - elevated only on my weak leg toes- my uninjured foot off the ground.

So with all that progress, I seemed to be very close to doing a single heel raise. Yesterday afternoon, I decided to try.

And- I did it!

I wasn’t able to lift myself very high, but I definitely got my heel off the ground for a few moments. So next, I decided to try and extend the range of motion a bit. I got a ~1" riser, and put the ball of my foot up on it. At first, it didn’t seem possible. I did a few with my strong leg, just to "practice", and make sure I was familliar with the motion (seems silly, but it helped). Got my toes set…

And- I did it!

No real pain, reasonable range of motion. I was very excited. HUGE milestone reached.

Emboldened by my success, I decided to do another one. Toes set. Balanced. 1.. 2.. 3..

POP!

Ok, maybe pop is a better description. But something let go at the injury site.

I sat down, took my shoe and sock off, and examined the Achilles. There was some pain, but not too severe. Everything seemed intact. I think it scared me so bad - that "pop" a brutal reminder of the initial injury - I got a little nauseous.

Nothing but ice and elevation last night.

I’m not really sure what I did. I’m not even convinced it was necessarily bad. It didn’t seem to swell at all. I feel no voids, gaps, or other defects in the Achilles. When I got on the spin bike this morning, in one way, I almost felt better. Since the surgery, I’ve had to fight a tendency to pronate my foot: when pedaling I seem to drive through the inside edge of my foot, and struggle to apply pressure flatly distributed across my whole fore-foot. Today, my foot seemed to sit more naturally on the pedal; though there was some unusual pain in my calf.

Climbing the stairs today, I feel tightness, but it’s shifted. It’s always been tight on the outside… after yesterday’s pop (which seemed to be localized to the outside, where that tightness was), I’m now tight on the inside. I did not try to keep my heel elevated on the stairs today.

Passive dorsiflexion actually seems improved a bit. Again, my limit seemed to be near the location of the pop; my new limit is shifted to the (opposite) inside.

Time will tell I guess. I think this may have been a necessary step backwards to enable future forward progress. My guess is that I might have tore up some load bearing scar tissue. I think the symptoms of a partial re-rupture would be much worse than what I’m experiencing.

I do think it will be a while before I try unassisted heel raises again. This may have been a minor physical setback- but my confidence is completely shattered. It’s back to baby steps with this thing.

Through this ordeal, I’ve tried very hard to stay positive- focused on the things I can do, rather than the things that I can’t.

Today, I  ran into an issue with my insurance company.  They reviewed  my latest report from PT, which documented my progress and activity level.  They decided that I was recovered, and no longer in need of (ie. they’re no longer paying for) further PT sessions.

I’m still inside of 12 weeks, and as per our strategy, we really haven’t started any strength and passive ROM work.  We’ve been patiently waiting for that 12 week milestone.   In support of our effort to secure further PT, I’ve been forced to take the pessimists view, examining and documenting the limitations that still remain. I thought it might be useful to share it here:

• I can’t run. I can’t even jog.  I can sort of do a half-hearted jog on the treadmill.
• On the bike, I can’t sprint, apply a lot of power, or jam out of the saddle.   I don’t think I can ride my road bike yet, it doesn’t have the gears I’d need to climb the big hills around here.
• Longer hikes result in soreness, swelling, and temporary loss of flexibility.
• My passive dorsi-flexion is still very much compromised.   It’s a serious limitation for things like skating, or even ski-climbing.
• Bare-foot, I still tend to limp
• I can’t really do lunges, stepping forward with my good leg, requires pushing off with the toes of my weak leg, and I lack the strength to do so properly.
• I can’t jump, or do any other sort of plyometrics.
• I cannot do a single leg heel raise (unassisted).   I cannot support my weight statically, standing - 1 footed - on my toes (but I’m very close).
• I don’t think I could snowboard yet (I haven’t tried).   Digging in the toe-side edge is my concern (you snowboarders understand).
• I still have inflammation of my whole lower leg in the evenings, and have localized tenderness (sore to the touch) near the injury.
• Balance on the weak leg is significantly worse than on the strong leg.

Don’t worry… I actually think I’m doing pretty well, and remain upbeat.   But I’m a long long ways from being fully recovered.   If I had my way, I think I’d be in PT for another 3 months or so.

In my last post, I said I wanted to start making the transition from rehabilitation to training. I can’t ask the insurance company to pay for my training. But, as much as I wish otherwise, a major rehabilitation effort still awaits me- even if I’m able to overlap/augment it with some training.

Day 70: 10 weeks post surgery. Time for a status report.

I had another PT session this week, followed by an appointment with my surgeon. At PT, they did an assessment of my active (no external forcing) range of motion. After some stretching and massage, my two ankles measured exactly the same ROM, in every direction. My surgeon checked things out, and went through the report from PT. We spent quite a while chatting about my progress to date. Afterwards, he shook my hand- and wished me well; unless I take a turn for the worse, he’s done with me. I owe him a lot, including a nice framed picture - of me racing - for his wall.

I continue to work towards eliminating what remains of my limp. It’s a simple byproduct of the weakness in my calf: I’m not able to push off each step with normal power. I can make the limp go away by compromising the push with my strong leg (making them equally weak), but I’m not sure that’s very productive.

My biggest hike so far has been 3 hours, 6.5 miles, in the mountains, with a ~1200ft climb.

I am finally able to go down stairs normally- one foot after the other.

Working out on the treadmill, I’ve done ~30s bursts as high as 6mph, which, for me, requires a jog. I am still unable to jog normally (on flat ground) but I’m getting close. Something about the smooth action on the treadmill makes it a bit easier. The gang of 3 (Surgeon, PT, Wife) seems to want me to hold off on the running for a while. Months, perhaps. So… OK, I’ve put it on the back burner. I’ve never been much of a runner, it’s always been a means to an end. I’ve got plenty of other things to work on.

I’m still a ways off from being able to do a 1-leg calf raise. I’ve been doing light calf work at the gym, using a variety of machines and exercises to put the ankle through it’s range of motion with some resistance. I would hesitate to characterize these exercises as weightlifting. I’ve been keeping the resistance light- high reps, focused on good control, extension, and (easy) stretching.

To exercise the rest of the leg, I’m able to work around the injury. I’m doing full squats with as much as 225lbs (I know, sissy weight).

Driving through my heels, I can avoid over-loading the calf and Achilles. I just require enough strength and stability to support good form; I have enough for that. Walking to and from the rack, supporting approximately 400lbs on each step, is a slow cautious affair. I can lift heavy enough to get a good workout, and will probably just work on increasing reps/sets before moving the weights much higher.

The cycling I’ve been doing is well represented by the video in my last blog entry. We’ve been keeping to tame single track. Climbing, I still need to pedal in a relatively low gear, spinning at high rpm for horsepower. I’ve been giving the derailleurs a real workout- downshifting for little rises that I would normally just muscle over. I can now cautiously stand up while pedaling; partly cheating by carrying significant weight on my arms. I can also bump into my cardio limit, though I suspect my efficiency is lower than normal.

The snow is starting to fall here in Northern Utah- and the mountain biking season is rapidly coming to a close. It’s probably time to hang up the Kayak’s too.

Speaking of snow, I went and did a little skiing. None of the resorts are open yet here, and snow coverage is pretty thin. So, I used my backcountry setup to climb up the mountain, and poached one of the runs at Alta, where they’ve been making snow:

It’s not great skiing- but it’s skiing. At one time, I had serious doubts about skiing at all this season- let alone this calendar year; let alone in November; let alone by opening day; let alone a few weeks before opening day!!

I’ve saved my biggest development for last. I just reached one of the most important (to me) milestones of all. Everything I’ve done up to this point has, in some fashion, been working towards this event…

I put my skates back on!

I was incredibly shaky at first - to be honest, after the first few minutes, I wasn’t sure I was going to be able to do it at all. But, steadiness and confidence gradually improved. Perseverance prevailed, and I now find myself able to skate with reasonable - not great - form. The smooth application of power feels like it’s going to be a good way to continue to build my strength and flexibility. I can’t tell you how liberating it feels to be back on the big ice. I’m certainly not ready to race yet, and it will still be quite some time before I can blast off a starting line.

So what’s next? Now that I’m able to skate again, I expect much of my focus will be there. Working on getting lower (flexibility), building more power (strength), and endurance (conditioning). Over the next few weeks, my hope is to start making a transition from rehabilitation to (careful) training. Perhaps that’s just a mental shift in perspective.

I also plan to go to back into a hinged walking boot soon. Weather permitting, I think it’s about time for my next footwear upgrade:

Finally: I’m trying to stop referring to my right leg as the “bad”, “injured”, “gimp”, “duff”, “hurt”, “blown”, or “damaged” leg. For now, it’s simply my weaker leg… and I’ll be working to change that.