Oct 03 2012


Slow and steady

Posted at 3:33 pm under Uncategorized

Though frustratingly slow at times, strength:

and, Dorsi-flexion:

continue to improve.

51 responses so far

51 Responses to “Slow and steady”

  1. Scotton 03 Oct 2012 at 6:03 pm 1

    I want one of those tattoos!!!

  2. Kimon 03 Oct 2012 at 9:02 pm 2

    Nice DF, Ryanb!! Looks like you’re building that calf nicely.

  3. ryanbon 04 Oct 2012 at 9:36 am 3

    In that 1st picture, those are raised platform single heel raises on a Smith Machine. The bar is attached to cables with counter-weights- when empty, I estimate it to provide around 20lbs of resistance. With the bare bar, I can do fairly good sets of 10 or 15. With another 90lbs of weight (as shown in the picture) I can do an OK set of 8. With 180lbs of weight (1 more plate on each side), I can do controlled eccentrics (lift up w/ 2 legs, go down slowly with one), or support the weight isometrically.

    With my left leg, I can do easy sets with 180lbs; so there is still a very significant strength deficit to work on.

    I probably have less than 5 degrees to go, before my two legs will be equal on dorsi-flexion.

  4. ryanbon 06 Nov 2012 at 1:13 pm 4

    Last night, prior to the ice session, I spent quite a bit of time stretching and warming up. At the end of this warm up, I decided to measure, and see just how big the dorsi-flexion deficit was, using the “knee-to-the-wall” test. I was in Vibrams- basically barefoot.

    Imagine my surprise when I discovered… there was none. Actually, I could go a little bit deeper with my right side than with my left. Multiple tests, with different foot positions, ankle pronation, etc.; all yielding the same result: my right side was a little more flexible than my left.

    It’s not like going to two shoes or something- but in my book, that’s still a big milestone. It means I need to start doing a better job stretching my left, and work things a little more symmetrically. It also means I can’t use compromised dorsi-flexion as an excuse for poor skating form anymore ;-)

    One little step at a time-

  5. sspeedon 28 Nov 2012 at 1:54 am 5

    Nice Ryan! That is impressive! I like the tattoo as well!

  6. humblandon 02 Dec 2012 at 12:25 pm 6

    Hi Ryanb,
    I am almost 8 months from surgery and have good dorsiflexion strength. However, I have overpronation issues. The ankle collapses to the inside. I see that you struggled with this. How were you able to address it? Thanks, E.

  7. ryanbon 02 Dec 2012 at 6:30 pm 7

    I could probably write up a big long blog post on that topic. I actually became aware of ankle pronation issues about 6 months before the ATR. In my case, as I drove my knee forward, the ankle collapsed to the inside, and the arch started to collapse. Hard to determine the cause/effect relationship; but I found that aggressively supporting the arch helped greatly to reduce the ankle pronation. So, I got some good footbeds (Aline), and then further modified them - building up the inside edge - to help counteract any pronation. It made a big difference, and really improved the function of my ankle.
    After the ATR, I found that pronation was severe. But the solution was the same- using my aggressive foot-beds with arch support and and lifted inside edge helped tremendously.
    All this leaves me wondering if the pronation issues, and my correction may have been a contributor to the ATR. Pronation was so severe after the ATR, than I remain convinced that the Achilles is an important player in preventing pronation. A weak/stretched Achilles (post injury) seems to lead to pronation. So, pronation may be an indicator of a weak tendon (pre injury). Did 6 months of using my footbeds shorten the Achilles- perhaps leaving it susceptible to injury when I stressed it without support? I was not wearing my footbeds at the time of my injury. It might have been a factor I think…

  8. normofthenorthon 03 Dec 2012 at 1:15 am 8

    Fascinating thoughts about the pronation and the arch collapse correlating with the ATR, Ryan! I noticed that problem with my right foot starting almost 20 years ago, when a brilliant “Level 4 Examiner” ski instructor noticed that I wasn’t edging as much or carving as well with my right ski as with my left. Soon after, I noticed what my bare right foot was doing when I “edged”, so added support under the arch of my right skiing footbed. That improved my skiing, but certainly didn’t prevent my right AT from rupturing maybe a decade later on the volleyball court.
    That first ATR was repaired surgically, and the surgeon made it short. I haven’t noticed a change in my skiing, but a podiatrist recently told me that I’m doing a kind of pronation — dislocating a small joint in my right foot, ahead of the ankle on the medial side — when I walk, to compensate for my limited ROM in my ankle itself, from the healed-short AT-and-calf (more details on my blog).
    Since then, I tore the left AT and went non-op. That one has apparently healed a bit long, at least in the connection to the Gastroc, because my plantarflexion strength (1-leg heel raise) is wimpy. But in 5 ski weeks in Whistler since that second ATR, I haven’t noticed any problem with the edging on my left side, or with my left ankle pronating or my left arch collapsing. (Mind you, I’ll be looking for it more carefully when I ski this season!!)
    Ryan, I also question the assumption buried in your “pronation may be an indicator of a weak tendon (pre injury)” — namely, that our ATRs were preceded by a general weakening or deterioration. Maybe, but it’s not obviously true, to me.
    But I do fit your model in one way: at least for my first ATR, I had been using a firm arch support to combat pronation and arch collapse SOME of the time (when skiing), but NOT when I tore the AT (playing court volleyball).

  9. ryanbon 03 Dec 2012 at 11:01 am 9

    > So, pronation may be an indicator of a weak tendon (pre injury).

    “Weak” probably wasn’t the word I should have used there Norm, at least in regards to the tendon itself.

    Coming off the injury, the ankle pronation was so much worse for me (and so many ATR patients seem to have issues) that it seems obvious that the Achilles tendon must play a significant role in supporting the ankle against pronation.

    Beware: from here on is nothing but wild speculation on my part…

    So, if you’ve got bad pronation issues (pre injury) one possible contributor is that the Achilles isn’t giving you the support it should. Now, does that mean your tendon is “weak”? Probably not. It probably means that a muscle upstream of the tendon (in your calf) is weak- or possibly that the tendon is a bit long - maybe not uniformly, perhaps one side/band of it has stretched. It might mean that (sprained ankles?) you’ve got loose ligaments, and are relying too much on the tendon (to support against pronation), which stretches it out over time (or stretches the muscle(s) above it).

    Anyway, my thinking is… what happens if you go “fix” such a problem quickly. Perhaps, by always supporting the arch (footbeds) leading to something recovering and/or shortening back to it’s proper length. Maybe good support allows a muscle to strengthen. Ligaments are much slower to “heal” than muscle- so (maximized at around 6 months…) you’d end up with a “partial” fix.

    Now, take away all that support, and apply maximum load. Does that “fix” lead to a stress concentration? A “short” achilles (partial achilles?) taking way more than it’s normal share of the load? Is that stress concentration maybe what starts the “tear”? Like I said, just wild speculation here… but the engineer in me sees a path where this could at least be a small player in the big ATR equation.

  10. normofthenorthon 03 Dec 2012 at 2:30 pm 10

    Still fascinating. Tiny sample here, but around 30 years ago I did pass through a year or two of WAY too many ankle sprains. First one was during a squash match. I was standing on the “T”, “packing sand” (= shifting weight quickly from foot to foot), preparing for my opponent’s shot, when I inexplicably rolled over an ankle. Huge pain — way worse than either ATR, BTW! — and a couple of days of hopping and hobbling afterwards.

    For the next year or two, BOTH of my ankles took every opportunity to do the same. :-( Once I was running down the center stairs in a big theater, turned the corner at the bottom and WHAM! Once I was walking on the raised (poured concrete) walkway in my back yard and stepped on the edge of the walkway and WHAM! I soon switched from low volleyball shoes to high basketball shoes in the hope of avoiding a sprain on the courts (which never happened!). After a couple of years, they stopped happening, and I’ve been pretty free of sprains (touch wood!) for maybe 25 years.

    All of that was before the ski footbeds, and before the two ATRs.

    I’ve also had a few random ankle-rolls in volleyball over the decades when stepping or landing on a teammate’s foot. That’s “an occupational hazard”, IMO, not a sign of any ligament problem. The latest was just a few years ago, right side. I hobbled off the court, but I think I was playing again a week later. (When NON-volleyball players hear that one player comes down from a block on top of a teammate’s foot, they feel sorry for the foot on the BOTTOM — but it’s actually the one on TOP that gets carried off the court!)

    Feel free to speculate! :-)

  11. humblandon 05 Dec 2012 at 11:13 pm 11

    Hi Ryan and Norm,
    Thanks for the feedback. I’ve been following your blogs since my surgery and I’ve learned so much; and felt comfort and assurance in your wisdom and experience.
    I’m 59 years young now, but have a lifetime of wear and tear on my body, including HS and college basketball and tournament tennis. I can remember numerous ankle sprains as a kid (b-ball). It may be that the lateral ligaments are just stretched out and the inevitable weakness from the ATR rehab exacerbates the problem. I’ve been wearing “Superfeet” orthotics for years (flat feet). Perhaps I should try a custom made pair… Lately, I’ve been consciously “weighting” the outside of my feet and trying to avoid rolling inward. It seems to be helping.
    Following surgery, I did an early weightbearing protocol including jogging, but no “active” stretching or sprinting until 6 months (Dr’s orders). Despite 7 months of daily training, the ankle still feels “weak” and “loose”, with numbness/stiffness on the lateral and posterior sides, but no pain. I’m trying to be patient, but I can’t imagine playing tennis or any activity which requires ballistic changes of direction.
    One question: I’ve been wondering if taping the ankle for support would help. Do either of you tape before athletic activity?
    Again, thanks for help and inspiration.
    Happy Holidays to all from a geezer jock.

  12. ryanbon 05 Dec 2012 at 11:44 pm 12

    Haven’t taped my ankles for many many years (football). However, none of the sports I regularly do involve the type of lateral explosive movements that taping would typically be used to support. I’m mostly a cyclist, skier, weightlifter, and speed skater. All of those things are controlled (from an ankle perspective), except for skiing- and in that case I’ve got way more ankle support from the ski boot than tape could ever provide.

  13. normofthenorthon 06 Dec 2012 at 4:04 am 13

    I guess my main AT-intensive sports — beach and court volleyball — are more “ballistic”, and involve more lateral explosive movements. . . but I’ve never taped my ankles, and I don’t now. As I indicated above, I did wear high basketball shoes for court volleyball for a coupla years when I was spraining my ankles. Maybe they helped? Hard to be sure. There are some people hereabouts who’ve returned to sports with various brace-like addons, not me.

  14. humblandon 07 Dec 2012 at 7:19 pm 14

    Hi fellow athletes,
    Thanks for the information. Following Norms suggestion I searched for bracing and found some interesting posts. This product looks promising:
    Prior to the injury, I was a high level senior tennis player (Semifinalist-US National Championships).
    Tennis requires explosive ballistic loading and directional changes…
    In searching online, I’m not sure a player has ever come back from this injury to compete at a high national/international level. It seems it’s often a career-ender for basketball and tennis players. Misty-may Treanor made it back to volleyball. It took her 18 months (and she was in her 30’s), but she won Olympic Gold. I would welcome the opportunity to correspond with any other athletes that have made it back. Perhaps they can help point the way. Does anyone have suggestions?

  15. kkirkon 07 Dec 2012 at 9:49 pm 15

    Man Ryanb the DF looks awesome! Hopefully, (:fingerscrossed) I get there also (slow and steady). :)

  16. humblandon 10 Dec 2012 at 11:11 am 16

    Hi Ryan And Norm,
    This is a follow up on our “pronation” thoughts. A search turned up this post:

    # Doc Rosson 30 Oct 2008 at 11:22 am
    To All,
    Just received “The Achilles Tendon” Book and have all ready learned a few things.
    First the soleus and the gastroc tendons insert on different parts of the calcaneus and actually spiral to promote better movement and stability. Obviously with surgery there is NO way to duplicate this and therefore we are never 100%. crap
    Second…the AT actually sends fibers to the plantar fascia for support but again post surgery this change in mechanics can lead to plantar fascitis down the road. Thus make sure you get fitted for orthotics!!!!
    …..and I’m only on page 8.
    As I come across more info I will pass it along.
    Go forth and heal….
    Doc Ross

    It makes sense that the “spiral” structure of soleus and gastroc help stabilize the ankle and keep the foot from collapsing inward. This spiral is probably compromised by the surgery. The nerve function is probably impaired as well.
    Norm, this is a powerful argument for your non-surgical treatment. If the leg is casted in an equine position and the casts are progressively shifted to neutral over 6-8 months, then the damage from the surgery is avoided. If combined with early weightbearing (in the cast), some muscle atrophy can be mitigated. Then it’s the long rehab road back (perhaps years) to regain strength and function.
    In my case, I’m 8 months from the surgery and I’m not optimistic about a return to competitive sports. I was a high level senior tennis player (Semifinalist U.S. National Championships). Strength is slowly coming back, but the damage from the surgery itself seems to be an issue…If I had to do it again, I think I would elect to try the conservative approach first. After all, there is no quick fix for this injury. Why not see if the body can heal itself? If the result isn’t satisfactory, then surgery is still an option later on…
    It seems similar to the course of orthoscopic knee surgery. My understanding is that it is no longer performed to a great extent; as the double blind studies showed that there was no long term benefit. The people who had the surgery had long term debilitation from the surgery itself…In the mean time hundreds of thousands of people unnecessarily went under the knife.
    I believe that Norm’s Canadian protocol is a more rational approach.
    One other side note: I wore orthotics for years prior to the injury. When I was in the cast and boot, I had progressive heel lifts in place. I now think that they should have included an orthotic in the cast and boot. This would have added medial foot support and encouraged healing in a more “functional” position.
    Medicine is slow to change. I’ hoping that this dialog can reach a few open minds and stimulate thinking…
    Happy Holidays to all,

  17. ryanbon 10 Dec 2012 at 12:53 pm 17

    Interesting info Humbland.

    It makes sense - especially if you look at some surgery pictures that have been posted - that the intricate spiral structures can’t be replicated during surgery. I think it’s really all they can do to get things pulled back together and secured with sutures.

    My question however would be: is there any evidence that a non surgical re-attachment does any better in this regard?

    BTW- I agree with you about orthotic support in the boot. In fact, I inserted my own orthotic footbeds in my boot during PWB and FWB periods.

    FWIW, at ~15 months, I’m not feeling like I have any remaining side effects from the surgery. No adhesions, numbness, nerve damage, etc., that I can detect. My foot still pronates- but I can’t honestly say that the issue is measurably worse than it was pre-injury. If *I* had to do it all again- I’d probably take exactly the same route (immediate surgery).

  18. normofthenorthon 10 Dec 2012 at 2:38 pm 18

    Humbland, I don’t think there’s much to choose between the two approaches in ultimate end-points, and I think you’ll do better than you now expect/fear. I notice NO performance deficit in volleyball after TWO ATRs, despite a nearly non-existent straight-kneed 1LHR on the left (2d, non-op) side. Some inconclusive and conflicting evidence:
    - A study of NFB football players post-ATR (all -op) showed few returning to their former elite status, though a few did. Very “ballistic”, I think.
    - IIRC, the 2007 op/non-op study from NZ found only 1 stat-sig difference between the randomized groups, & in that 1 test the non-ops were stronger than the post-ops. But the UWO results went the other way: a general non-significant bias in favor of the post-ops, with one measure reaching stat-sig.

    It’s hard to conclude that non-op reconstructs that spiral better than surgery based on today’s evidence. Mind you, we probably haven’t perfected either cure yet. I “push” the non-op approach, not because I think the results are better on avg, but because I think (1) they’re either “just as good” or virtually so, (2) skipping the pain and time-off-work and drugs and expense and risk of scary side-effects is a worthwhile benefit IMHO, & (3) I still see the surgical path being over-pushed to most patients in most jurisdictions by most “experts”. I think surgery should bear the burden of proof, and it no longer meets that test. And I think most OS’s think non-op bears that burden, which is crazy and backwards until you remember that you’re dealing with humans.

  19. ryanbon 10 Dec 2012 at 3:14 pm 19

    Brings to mind a famous quote:

    It is difficult to get a man to understand something, when his salary depends upon his not understanding it!

  20. humblandon 11 Dec 2012 at 11:14 am 20

    Ryan and Norm,
    Thanks for the thoughts.
    After extensive study of (recent) online lit, I tend to agree with Norm. The non-op protocol has more going for it. However, it’s such a tough sell when people (particularly athletes) are so shocked and devastated by the injury. I know that I wanted it “fixed” as soon as possible…What I failed to grasp at that moment is that there is no “quick fix” for this. No matter what you try, it will be a long row to hoe. What have you got to lose by starting slow?
    I was lucky to have one of the most respected orthopedic surgeons. He specializes in foot/ankle and has done a number of athletes (some very accomplished).
    Here’s a direct quote from my surgeon “I’ve done over 300 of these procedures and not a single patient has been happy” (with the course of treatment). That should tell you something…
    Norm and Ryan, both of you are inspirational “torch bearers”. This site is a beacon of light in the darkness.
    Norm, I hope you are right about my long term functional “outcome”.
    Ryan, I wish I had your “drive”, I would have probably accomplished more in the game (tennis).
    You are both inspirational to me…

  21. ryanbon 11 Dec 2012 at 1:00 pm 21

    Sometimes I probably come across as a surgery advocate- I’m really not. I’m a “do what you think is right” advocate :-)

    There are times when I think surgery is necessary (really stale injuries, multiple failures non-op, etc.). I think Norm would agree. Likewise, there are probably cases (weakened immune system=high risk of infection, or no medical insurance= very high out of pocket surgery cost, for instance) when surgery just makes no sense at all.

    But, for the vast majority of typical cases, I believe either route is viable. I’d encourage patients to learn all they can, and make an informed choice. My disposition is such that I don’t think I would have (mentally) dealt very well with the uncertainty of the non op route… it was re-assuring to *know* the tendon ends were attached, and unless/until I felt ‘em rip/pop apart; I had confidence that they were connected and healing. That confidence was important (to me) when pursuing the very agressive rehab schedule I chose. Is that peace of mind worth the price of surgery? Are there any other benefits? (I personally think the jury is still out on a few topics)

    I beleive each individual should look at the studies/evidence, weigh their options, and decide for themselves. But - unless it’s one of those outlyer cases mentioned above - I would never try to convince somebody who’s chosen to go non-op to get surgery instead.

    Thanks for the kind words Eric.

  22. humblandon 12 Dec 2012 at 11:15 am 22

    Hi Ryan,
    You have clarified your position and made some valid points, as always. Like you, at the time, I wanted to “know” that the tendon was repaired. It’s only after 8 months that I’m asking myself about the cost of “knowing” that the tendon is repaired.
    Hindsight is 20/20.
    I concur that the jury is still out (amazing in of itself after all the years this injury has been treated)… It tends to happen in older athletes. The demographics are such that there are now more baby boomers “pushing the envelope” of performance. From what little information I can find, very few senior athletes are able to return to their sport at a pre-injury level.
    If specific athletic performance is not an issue, then either non-op or surgical protocols have their strong points (as you stated).
    In order to determine if specific athletic performance goals are attainable, accomplished senior athletes need to “bite the bullet’” of uncertainty and try to come back with a non-op protocol. The social pressure to adopt the “party line” (and have the surgery) is overwhelming. People in the midst of the injury crisis are ill equipped to slow down and consider other possibilities. It took me weeks of sifting through the articles and data to realize that non-op was a viable option. By that time, I was recovering from surgery. Even then, with the lack of performance specific data, I’m not sure that I would have not opted to go under the knife…
    Norm is an “n of 1″ in that he may be the only senior athlete to have tried both non-op and surgical protocols. He is a serious competitor and his sport (volleyball) requires ballistic loading of the tendons. He is a thoughtful and articulate spokesman for the non-op course. That says a lot…
    In the end, everyone must make there own choices. I only hope that our dialog sheds some light in the darkness and helps people with peace of mind. For me, this has been a life changing event, with an opportunity for reflection. It’s been difficult to deal with the fear and uncertainty. I’m grateful for everyone’s contributions and support.

  23. normofthenorthon 12 Dec 2012 at 2:50 pm 23

    Eric, you’ve spurred a great discussion, IMHO! I wish everybody who’s just ruptured an AT could read it, and see the extent to which Ryan and I agree about the facts (~98+%?), and about the multiple factors that SHOULD go into an ATR patient’s informed consent to follow either basic treatment path (and all the other forks in the paths, too, while we’re at it). Maybe Dennis could link this page from the “So You’ve Just Ruptured Your AT” page?

    I’ve commented “+1″ to a pretty huge number of Ryan’s posts over the past few months, and I feel the same way about his posts above. What’s fascinating about that is that we often approach questions similarly and seem to have similar modes of thought — yet we still “agree to disagree” about which way we lean, e.g., what we would do if we personally faced this decision again. And as Ryan suggested above, I have STRONGLY urged a number of those “outliers” — especially people with “stale” ATRs — to get the surgery, while I still lean toward non-op for standard sports-type overstress ATRs caught promptly.

    BTW, I think it is a very logical hypothesis to suggest that non-op results deteriorate significantly with pre-treatment delay, even within the 2-week “window” that most studies (including UWO) use as a criterion for inclusion. I’ve urged a few of the UWO Study’s authors to “mine” their data to test that hypothesis, but I haven’t even heard back. (That’s where I stand on the scientific-academic totem pole!)

    If that hypothesis turns out to be true — and it seems that post-op results are comparatively insensitive to pre-op delay — then it may well turn out that ATR patients who begin non-op treatment very promptly are already achieving results that clearly BEAT surgery! Heck, we know that a sample of ATRs randomly spreading from “just now” to “2 weeks ago” comes up with virtually identical clinical results. . . We also know that the David Beckhams of the world don’t waste much time between an injury and treatment, so it’s possible that all 3 of us will live long enough to see the Standard of Care for elite athletes shift to (super-prompt) non-op. Possible.

    As part of the nuanced and multi-factorial and jury-still-out case for and against ATR surgery, it may be worth mentioning that this particular “n=1″ sample — maybe n=2, given the two ATRs, treated differently — ended up with significantly weaker calf strength on my non-op side than my post-op side. Mind you, my current Podiatrist is more worried about my post-op ankle (short AT) than my post-non-op ankle (probably long AT connection to the Gastroc). And also mind you, I really can’t notice any performance deficit in running or jumping or volleyball or bicycling — only when trying to do a 1-leg heel raise!. But still, if I thought my two results were the two guaranteed results, I’d be more hesitant to recommend non-op to my athletic friends than I am.
    Peace to you too.

  24. ryanbon 12 Dec 2012 at 3:18 pm 24

    +1 Norm :-)

  25. humblandon 13 Dec 2012 at 11:42 am 25

    Ryan and Norm,
    I hope that this dialog is made more available in some way. I’m not sure how to expedite it. Norm, perhaps you can help…
    Norm, I agree that the “delay in surgical intervention” question is the elephant in the room. I’m not sure how to make a rational case to address it. From what I can understand, elite athletes like David Beckham almost always have the immediate repair. I have not seen a reference to an elite athlete who adopted a non-op “wait and see” protocol. However, what must be considered is that most elite athletes are “on the clock”, with imense pressure to return to their sport asap. They can’t afford to “wait and see”. On the other hand, high level senior athletes, like me, are perhaps interested in maximum functionality vs speed of recovery.
    I have a life long friend who is a brilliant physician (Harvard and UCLA Medical School). When I was considering surgery for a knee issue years ago, he told me “there is not a single medical condition that you can not make worse with surgery”.
    I’ve been an athlete all of my life. Pain and injury come with the territory of pushing the envelope to the max.
    We live in an instant gratification society. Everyone wants the quick fix, including me. The body has an incredible capacity to heal itself, if given the chance. My question remains, “are we giving it that chance”? and “are there costs to giving it that chance”?
    One thing is certain. There are costs of the surgery.
    Again, thanks to all and

  26. ryanbon 13 Dec 2012 at 1:49 pm 26

    It is unfortunate that, for best results, the decision needs to be made quickly, often under some duress.

    Without question, I think ALL patients should immediately start on the non-op (immobilized, equine) path. If they decide on surgery, then no harm done. If they decide to proceed non-op, then they’ve got a head start, and have begun the healing process as early as possible.

    I fully realize that what I advocate (looking at the evidence, making a fully informed decision) isn’t always possible. If you’re going to have surgery, I think it’s best to have it quickly- and patients don’t have time to become ATR experts in that window. So, we end up relying on the advice of the medical professionals, which also seems to be a bit of a crap shoot.

    I also think it’s interesting that Norm and I agree on so much, but would take different paths if we did this again. Perhaps some of this is just confirmation bias (at least on my part)- but I honestly don’t think I could have hoped for a much more successful recovery, and would simply hope to replicate my result if this were to happen again. FWIW, my surgeon does have at least one patient happy with his result (me).

  27. kkirkon 13 Dec 2012 at 5:04 pm 27

    This has been one of the most informative discussions I have read since I found this site. I agree that this information should be more available to first time members/ viewers of Achillesblog. Had I been more proactive in my research and sought out this site earlier, my treatment could have been vastly different (Possibly No-op), but the delay from what I now believe was a partial tear that later became A full rupture, wouldn’t have needed a surgical procedure to repair the tendon. Please continue the discussion :)

  28. normofthenorthon 14 Dec 2012 at 12:28 am 28

    Ryan, I was also looking for another “surgeon surgeon” after I had my second ATR, 8 years after a pretty routine and apparently successful (though REALLY frustratingly slow!) surgical repair and rehab on the first one. I never seriously considered non-op treatment in 2009 — still based on my research back in 2001 — until I met my fancy sports-medicine surgeon. He’d been persuaded by a pre-pub presentation of the UWO study’s results, and had decided to stop doing ATR surgery. “The study shows that the surgery has no benefit compared with immobilization, and I didn’t become a surgeon to do surgery with no benefit!” he told me. My Dad always said “If you go to a carpenter, expect him to recommend wood,” so I was persuaded pretty quickly. It’s not as if I’d ENJOYED the surgery (or the moaning and groaning and time off, or the scar. . .) the first time. . .

    Eric/Humbland, I don’t share your characterization of the non-op protocols as “wait and see”. Of course it’s true that if non-op treatment fails, there’s a surgical fallback. But that’s also true of surgical treatment, isn’t it? ANY treatment has a “wait and see” aspect to it, unless success is guaranteed, and it usually is not. But going straight into a fixed boot with 2cm heel lift (or the hinged-boot equivalent) ASAP after an ATR and continuing on the UWO protocol is being about as pro-active as scheduling surgery IMHO, even though it may not scratch all the same psychological itches.

    The time pressure to return to elite sport doesn’t seem a big factor, either. Sure, it’s a huge pressure, but the schedule that most post-op ATR patients follow (including Beckham, as I recall) is no faster than the UWO non-op (and post-op) patients went. The only good-sized group of patients I’ve ever seen that went significantly faster, were a group in Japan that got an experimental suture and “flew” through rehab — more details on my “studies” blog page. If Beckham had flown to Japan for that surgery, and healed only as fast as an AVERAGE patient, he could have played in the upcoming World Cup! (The study doesn’t mention how brilliantly the patients did in sports, just when they returned! :-) )

    I agree with all of Ryan’s latest post, too (surprised?). The fact that most surgeons think a surgical repair works best on “fresh” ATRs obviously works against patient research and empowerment and even informed consent. BTW, I’ve never seen any evidence supporting the bias toward quick surgery, and my fancy surgeon told me that he always preferred operating on ATRs that had had ~2 weeks to “mature”. He said that the interval gave the torn ends a chance to get tighter and more compact, so easier to stitch than the original frayed ends. Mind you, if you were preparing for HIS operating table, you probably would NOT want to be immobilized at the perfect angle, because that would make the ends heal together, which might not be as good. (Not that a partially healed AT would be hard to slice apart and reattach. . .)

    But I agree that anybody who’s diagnosed with an ATR should go straight into a properly-aligned boot, and be NWB on crutches, while thinking, learning, and deciding about surgery.

    KKirk, I’m not sure there’s a lot of “legs” left in this discussion. I think we’ve covered the ground of what’s known and not, and how the decisions are, and should be, made. And covered a range of reasonable and reasoned opinions, too. Maybe I’ll include a link to here on some of my blog pages about this decision, which might draw an extra few pairs of eyes. I think Dennis probably already got notified of it (He gets notified whenever his name is mentioned on this site, AFAIK, and I’ve done it TWICE now!), so if he thinks it’s worthy of being linked in the “Studies and Protocols” page or in “So You’ve Just Ruptured your AT. . .”, he’s free to do it — or not, as he sees fit.

  29. humblandon 14 Dec 2012 at 11:50 am 29

    Hi Norm,
    Perhaps I should rephrase my post a bit.
    By “wait and see”, I meant that surgery is always an option down the road. It will take considerable time (6 months?) to determine if the patient is “satisfied” with the results.
    I think that most elite athletes are “sold” that there is no option other than immediate surgery. Also, pro athletes are often employees of an organization that “calls the shots” or at least has a huge stake, and presumably input, into the welfare of their “investment”. It seems likely that they are liable to go with the party line… The perception being that if conservative treatment does not “work”, then the athlete has “wasted” at least 6 months of recovery time prior to starting down the long surgical path.
    Current evidence (to support conservative treatment instead of surgery) is spotty and difficult to locate. There are very few vocal advocates (present company excluded). I agree, that there should probably be some sort of protocol involving immediate cast/boot with a heel lift (and orthotic) for a few weeks while the patient is allowed to study/consider all options. I believe that the “rush” to surgery is a mistake. If at least one person slows down and thinks more carefully about the process, then we will have accomplished something significant with this dialog.
    I agree that asking a surgeon weather or not you should operate is like asking a banker where to invest your money (he’ll say in my bank at 1% interest).
    Note: my surgeon thinks that I have had a remarkable recovery. I’m grateful to be able to walk and be active again after the shock and fear of the injury. The fact that my foot does not function well enough (after 8 months) to play tennis is perhaps not relevant to most people’s expectations. Selfishly, I’m hoping that more time and rehab effort can effect the progression.
    Norm, when you talk about your non-op leg, it seems clear that you seem to feel that your repaired leg is stronger. What I’m “hearing” is that despite this fact, you don’t think the surgical trade off is worth it. That’s an interesting perspective, and obviously carefully considered.
    I remember when orthoscopic knee surgery was “the way to go”. Now, many serious injuries, like ACL tears are treated conservatively…
    The bottom line is, that surgery is “forever”. What’s done can not be undone. It takes courage and patience to go with the conservative protocol first.
    I agree, that we seem to have exhausted this discussion. If anyone has new information about training for lateral stability and strength, please post it.
    Thanks and happy holidays,

  30. normofthenorthon 14 Dec 2012 at 12:45 pm 30

    Eric, I’m still hopeful about your recovery because 8 months is still early times for sports. I waited ’til 10-11 months the first time, then I was fine. That timing was based on my ultra-conservative OS’s direction that I wait ’til I could do a bunch of 1-leg heel raises without grunting before returning to volleyball (all court v-ball at the time, beach came later). When I last saw him at ~6 months, I could grunt out a couple of raises.

    And Eric, I’m intrigued by your “it seems clear that you seem to feel that your repaired leg is stronger. What I’m “hearing” is that despite this fact, you don’t think the surgical trade off is worth it. That’s an interesting perspective, and obviously carefully considered.” Yes, I have a two-leg “A/B” comparison, but that’s only a database of n=2. My repaired leg is definitely stronger, no doubt. It can do a bunch of 1-leg heel raises, and the other one can’t. There’s no subjective “seem to feel” involved — heck, I’ve even had the two measured on a huge computerized gizmo, though my non-op recovery wasn’t complete when that happened.

    But I’m too much a scientist to think that my experience — what you call “this fact” — is a strong predictor of what will happen to the NEXT ruptured AT that’s treated surgically or non-surgically. It’s an anecdote, right? The fact that it’s MY anecdote makes it important to me, and the fact that I’m blabbing about it here with an audience that’s unusually (if not morbidly) fascinated with all things ATR, makes it seem important to some others. But it’s still an anecdote, n=2 ATRs. Fortunately, we have some other randomized trials like Twaddle/NZ with n=40-something IIRC, and UWO with n=~150, which give us a much better predictor of what will happen to the next ruptured AT. And they both suggest that the net benefits of surgery are either tiny or non-existent — on average, using fast modern protocols. That’s the main basis of my preference for non-op — as well as my desire to “balance” what I see as an irrationally pro-op bias among health professionals and authoritative websites and others who should be reflecting the best evidence.

    Also, the surprising fact that my measurable and factual left-leg strength deficit has had ZERO perceived impact on my performance in a number of explosive and competitive sports, has made me question the “obviously logical” assumption that powerful 1-leg heel raises can make the difference between sub-par and outstanding sports performance. (Ryan, it’s possible that excellent speed skating really DOES depend on the same strength that’s measured in 1-leg heel raises. But I would have bet big money that court volleyball did — until I spiked a few balls from my usual pre-ATR height over the net, as a post-ATR left-legged spiker with a wimpy left-leg 1-leg heel raise!)

    So here’s my dream: A future version of Apple’s “Siri” (& other-brand equivalent AI guides) notices that its owner has suffered an ATR, and immediately delivers a menu of choices that includes this page and the Web’s only free full-text version of the UWO study (on this site) and another handful of carefully selected links to guide this important decision. :-)
    BTW, I don’t insist that anybody spend weeks in a boot thinking about op vs. non-op. But IMO, the first few days post-ATR, while thinking, should always be spent in a properly angled boot and NWB on crutches, so the very best non-op treatment is an available alternative to the knife. Emergency rooms (A&E in the UK) should be redesigned to send ATR patients out that way, with appropriate printouts taped to their crutches (see “Siri”, above)!

  31. humblandon 15 Dec 2012 at 11:03 am 31

    Norm and Ryan,
    In re-reading the posts and following Norm’s references to the various studies, I’m left with a few questions:
    Is there any direct correlation between delay in surgery and long term functional outcome?
    In looking at the early weightbearing protocol that Ryan and I (and many others here) have followed. Is there any correlation between early weightbearing and long term functional outcome? Also, is there any correlation between the risk of healing “long” and early weightbearing and/or accelerated rehab/recovery?
    Ryan mentioned that after 15 months, his repaired leg is still weaker. I’m assuming that this means that he has difficulty with full height 1-leg heel raises.
    From what I’ve read, this seems almost inevitable, no matter how aggressive your rehab schedule (think Ryan). After 8 months of daily training, I can do “whimpy” 1-leg heel raises, but a full height raise is not “on the radar”. In fact, improvement in this metric seems to have stalled out. Ryan, have you been able to make any further progress? Has anyone been able to get back to equal strength? If so, how long did it take and were there any “outside the box” training tips that helped?
    Is diminished 1-leg heel raise height is a consequence of the injury itself? or the surgery? Or is it a consequence of healing “long” from too aggressive rehab?
    Does anyone know the answers to these questions?

  32. Xploraon 15 Dec 2012 at 3:35 pm 32

    Eric - go to my page and in the tab ‘further reading’ there is a link to a study on early weight bearing for surgical patients. It relates to many of the questions you have asked. I followed an aggressive program and can do many full height single leg raises but I am sure there will be some small deficit in the repaired leg. It doesn’t seem to affect anything I do. One important thing I took from this study is that both groups had a similar result long term. So those here that are following an old and slow way need not fear that it will impede their long term recovery.

  33. normofthenorthon 15 Dec 2012 at 4:03 pm 33

    Eric, those are great questions, right up there with the question I’d love to get the UWO authors to answer from their data. The overall answer to your “bottom line” question — “Does anyone know the answers to these questions?” — is “Not really, not based on good evidence,” IMHO.

    The Q about pre-surgery delay is no more studied than pre-non-op delay (my fave), because many surgeons hate operating on “stale” ATRs, so they’re usually excluded from all the studies. Some OSs either tolerate or even prefer staler ATRs, so delayed repairs are generally available. My impression is that (a) there’s a higher % of grafted repairs than among the prompt repairs, based on undocumented “logic”, and (b) the results I’ve heard anecdotally don’t seem obviously worse than those for prompt surgery, but expectations are often lower, again based on undocumented “logic”.

    The Q about the impact of early WB has been the subject of a number of randomized studies, several of which are linked in this site’s “studies and protocols” page. My recollection is that those studies (all post-op only) generally show that early WB — as early as they went — gives results that are no worse than slower rehab. Some were a bit better, but most seemed close, IIRC. (Please correct me here if I’m wrong; I haven’t ever read more than Exec Summaries, and that was a while back.)

    The UWO study probably gives the most careful and best-documented post-op and post-non-op results for strength and ROM (which is treated as a proxy for “healing long”, though even THAT assumption may be wrong!) and re-rupture rate. Still just one study, though. IIRC, their average patient, either way, still had a strength deficit at 2 years. I don’t recall if they presented the data in a way that lets you determine what % of patients had no deficit, or came out stronger. Did you notice?

    My own experience with ATR #2 (left, non-op) has made me question my long-held assumption that “healing long” can be diagnosed by functional weakness AND by unusually high DF ROM. My left Gastroc contracts much farther-higher than my right, which “proves” that a too-long connection is the cause of my wimpy left-side 1LHR. But my left-ankle DF ROM — measured by the knee-to-wall test, checking the distance from big toenail to the molding — is exactly identical to my right (ATR #1), which was clearly repaired short, short enough to worry my current podiatrist about my future mobility. Of course, this particular test is done with a bent knee, and I’m told that bent-knee strength (and presumably ROM) depend more on the AT connection to the Soleus than the connection to the Gastroc (which comes into play with straight knee). I think my left Soleus connection healed well post-non-op, not long. (I suspect that’s why I notice no athletic performance deficit, too.) Perhaps a PT with a protractor would find my left-ankle DF ROM is abnormally high, but not that knee-to-wall test.

    OK, I just tried leaning toward the wall straight-kneed with my bare feet flat on the floor, seeing how far I could get each foot behind me. There might be a cm or 2 difference. (And I THINK I’m avoiding dislocating that other ankle joint that my podiatrist is worried about on my right foot — so many variables!) The difference (a) seems tiny compared to the strength difference; (b) is comparing my wimpy left to my repaired-short right, not to “original factory issue”; and (b) doesn’t obviously correspond to the difference in visual height between my two Gastrocs (both of them congenitally scrawny, BTW!).

    I usually avoid generalizing from my anecdotal experience or anybody else’s, but this time I think we’re dealing with the First Law of Physics, “If it exists, it must be possible”! At least in my case (ATR #2, left), which MAY have involved multiple ATRs (as 1 of my 3 UltraSounds “showed”!), my apparently long AT-Gastroc length does NOT seem to translate into unusual DF ROM. Maybe because the AT-Soleus length is “right”, and limits my DF ROM. I also did this test only once, before moving much, much less warming up and playing some 2-on-2 volleyball . (That was last night!)

    The only other non-anecdotal evidence that seems relevant is a survey of post-ATR NFL football players that I’ve mentioned before. There was a significant AVERAGE performance deficit, but some percentage did return to their elite athletic jobs, and a few recaptured or exceeded their past glory, IIRC. Just as none of us is guaranteed to equal the median results, none of us is limited to those results, either! (There’s a great essay online with a title like “The Median is Not the Message”.)

    Some of these ongoing mysteries are just the rational consequence of (1) a resource-limited world and (2) a non-life-threatening problem. Even in my other medical-research hobby field — heart-valve replacement and the adjacent problems and solutions — there are still lots of puzzles and paradozes and arguments about best practices. And that field is WAY less resource-limited and WAY more life-threatening.

  34. ryanbon 15 Dec 2012 at 7:35 pm 34

    Ryan mentioned that after 15 months, his repaired leg is still weaker. I’m assuming that this means that he has difficulty with full height 1-leg heel raises.

    I can bang out full height 1 leg heel raises. If you look at the picture, at the very top of this thread/page, you’ll see me doing heel raises with ~100lbs of extra resistance.

    I’d wager my right (injured) calf is as strong or stronger than the average guy off the street.

    The difference is that I can still do heavier weight, or more reps, with my uninjured side. I’m confident that I would have a bit less vertical leap on my injured side if I measured.

    I don’t, in any way, attribute this to the surgery. I just haven’t fully recovered the muscle mass and strength from the atrophy. My whole recovery strategy was based around minimizing the atrophy… I was mobile, weight bearing, and carefully working the calf as early as I could. Still, my calf suffered badly from all the inactivity, and (I think, in retrospect) protecting it from injury for so long. Heck, I am probably still a little bit (sub consciously) “easy” on it.

    Calves are just really hard muscles to build- and (like all of us), I was starting in a very deep hole ;-)

  35. normofthenorthon 15 Dec 2012 at 8:13 pm 35

    Sure, Ryan, use your fancy Admin priviledges to gussy up your posts with italics, see if WE care! :-)
    One more data point from me: A few years ago, I started wearing beach-volleyball footwear — first a pair of “Sand Skins”, then a pair of Vincere Sand Socks, with another pair of “Sand Skins” still stuck somewhere in the holiday mail. It just occurred to me that both of my used pairs have worn out faster on my right side than my left. The Sand Skins started failing at the toe. (I’ve since started trimming my toenails VERY frequently!). And the Vincere’s have started failing under the ball of my foot. But in both cases, the left one looks better than the right one, which is wearing faster. That’s notable, because I’ve always been “left-footed”, at least by the classic test: “When you run on an icy surface then stop to skid like a kid, which foot is in front?”

    Unlike some volleyball players, I do jump from both feet (to spike or block), but I’d still expect to emphasize my left side more, in general. (OTOH, I ruptured my right AT first, so the facts are messy and complex again!) But my footwear indicates that my right (post-op ATR #1, stronger and shorter AT) foot is doing more of the work. Also interestingly (though maybe only to me! ;-) ), the uneven wear on the FIRST pair came BEFORE my ATR #2, when I could still crank out a long string of 1-leg heel raises on either side — so maybe it doesn’t tell us much about my accommodation of a weaker post-non-op left AT-and-calf after all. Hmmm.

  36. humblandon 16 Dec 2012 at 12:49 am 36

    Can you post a link to the site and ‘further reading’ tab you mentioned?
    Ryan, I also followed an aggressive protocol to try and minimize atrophy. However my inner (medial) calf still shrunk in size. The outer (lateral) calf is similar to my “good” side. From what I can see, this is common. My theory is there is something about the surgery that compromises the medial calf motor response. After 2 years of hard work, it seems common to have a deficit manifested in this area. I have a friend (fellow tennis player) that is 2.5 years from the surgery with the same problem (strength deficit in the medial calf). I think he is about 80% back to his pre-injury level. This deficit remainder may be the most telling reason why most elite athletes can’t make it all the way back. However, for most people their daily lives are not effected much (if at all). Say you can get back 90% of function…that’s a good result. However, the difference between being competitive at the very top of the game is more like 1-2%. It’s that razor thin margin which stratifies people at the top. This is the voice of experience talking…
    My mantra is “Patience…”

  37. normofthenorthon 16 Dec 2012 at 3:27 am 37

    Can you post a link to the site and ‘further reading’ tab you mentioned?”
    It’s at achillesblog.com/xplora/links-for-further-reading/

  38. humblandon 16 Dec 2012 at 12:11 pm 38

    Xplora and Norm,
    Thanks for the links, I saw most of the information when I first found this site, after my surgery. However, it is good to review the studies and confirm my own subjective post-op impressions.
    Two things stand out:

    In the “conclusions” of the early weightbearing study from 2003 they said “Although this regimen shortens the time needed for return to work and rehabilitation to sport, gastrocsoleus muscle strength deficit and muscle atrophy are not prevented.”
    My question is “why is this so?” From my reading, the strength deficit and muscle atrophy are long term and persistent, even though it is clear that many athletes have trained hard and long to address it. Why is this deficit in muscle size and strength so difficult to correct? Also, given that this study happened 10 years ago, is there any more recent information that attempts to address these questions? You would think that someone would have “noticed” that no matter how hard the repaired leg is trained, equal strength/size is extremely difficult (if not impossible) to achieve…

    From the VACOPED acellerated Achilles Rehabilitation Program:

    “12-16 WEEKS
    Jogging progressing to fast acc. & deceleration.
    Directional running / cutting
    Pylometrics. e.g. toe bouncing upwards / forwards
    16-20 WEEKS

    To me, this seems incredibly unrealistic and I question how this information was obtained. Were there studies done using this protocol? If so, when and where were they conducted? Is this legit data, or are these people trying to sell their boot?

    My surgeon specializes in foot/ankle and is extremely experienced (>300 procedures) and has worked with a number of high level athletes. He maintains that there are “dangers” to some kinds of early activity. He
    would not let me actively stretch or sprint on the repair prior to 24 weeks.

    Everyone can’t be right…
    It’s frustrating and confusing to wade through the online information in search of kernels of truth.

    I believe that I have had a “good outcome” from surgery. My recovery profile fits right in with many (including Ryan’s) that I have read. I tried to balance my doctor’s wishes with the subjective material that I have found here and my own lifetime of athletics. At the end of the day (really only 8 months), I have a significant strength and functionality deficit in the repaired foot/ leg. From my reading and talking to other athletes, who are sometimes years down the road, this is “just the way it is”… My question remains “Why?”. It seems logical that the surgery itself is the “key” factor.
    My guess is that until there is a study that asks high level athletes to go non-op, with a “modern” accelerated weightbearing rehab and training, we will never know if this long term strencgth/size deficit can be reduced or eliminated.

    I think that much of what we see and read about the progression of this injury treatment is colored by the expectations of the people involved.
    That is, a “good result” for the surgeon is the patient walking and returned to work and daily activities at one year or sooner.
    On the other hand, a “good result” for the competitive athlete is an eventual return to full function in their chosen sport.
    It stands to reason that the two outcomes are not necessarily achievable with the same treatment protocol.
    At the end of the day, it’s difficult to do controlled studies on human beings. Like Norm, I hope to see the answers to these questions resolved at some point…
    Peace, Love, Hope,

  39. normofthenorthon 16 Dec 2012 at 2:50 pm 39

    The UWO Protocol seems a little more modest, and more open-ended (i.e. more vague >12 weeks). From “my” version at bit.ly/UWOProtocol :

    8-12 WEEKS
    -wean off boot
    -return to crutches/cane as necessary; then wean off
    -continue to progress ROM, strength, proprioception

    >12 WEEKS
    -continue to progress ROM, strength, proprioception
    -retrain strength, power, endurance
    -increase dynamic WB exercise, include plyometric training
    -sport specific retraining

    I don’t recall whether or not “your” Vaco protocol was used with a good number of patients, either post-op or non-op.

    It might seem logical to explain a long-term calf-strength deficit as a “good design” accommodation for the difficulty of rebuilding a scar-tissue link that’s as strong and resilient as the “original issue” AT, the strongest tendon (the strongest tissue!) in the human body. But the fact that roughly NONE of us ever re-ruptures a healed AT — especially in the same place — regardless of the abuse we subject it to… suggests that the healed AT is remarkably durable. Even allowing for the typical strength deficit, it seems likely that the average healed AT is stronger than “new”, and stronger than our other AT. So that doesn’t seem a likely answer.
    I also keep failing to reconcile your (Eric’s) bleak summary of the data with my own delightful return-to-sports experience. Granted, I’m not performing at world-class elite levels, but I do seem to be a huge outlier to perform at my level at my age, judging by my observations and the reactions of my 20-something and 30-something teammates and opponents. Hardly a scientific survey, but it does suggest that my surprising impression — that my volleyball performance is essentially restored to pre-2-ATR levels, despite a significant 1-leg heel-raise deficit on my left side — is supported by other (admittedly anecdotal) evidence. Sure I’d rather have a left calf that looked and performed heel raises the way it did 5 years ago — but NOT if that meant that it was 2 years away from rupturing, as it was then! Don’t forget that this glass is closer to overflowing than half-full! :-) Mind you, if my chosen competitive sport were 1-leg heel raises, or plyometric box jumps, instead of (largely beach) volleyball, the glass might look different.

    Eric, I’d keep working on strength and function. Give up the plans to become a leg/calf model, and focus on returning to sport by 10 or 11 months post-op, and see what happens. What’s the alternative?

  40. Xploraon 16 Dec 2012 at 4:05 pm 40

    Eric - I am not surprised how strong the repaired tendon is, as Norm has said. Look at the size of it compared to the other. It may not be as flexible as it was before and that could account for the strength deficit. (research function of AT and healing of tendons) There are also many variables with surgery including the number of surgeons. A surgeon will try to match the length of the ruptured tendon by looking at the other while you are laying on the table. Very subjective. A couple of mm long or short, how much difference will that make? The deficit is only measured against your other leg. Ryan is right, he is stronger than most others on the street. I would hazzard a guess that his repaired leg could end up better than pre op days with the amount of attention it is getting at the gym etc. In the end, it is not really size that matters but what you can do with it. It is still early days yet. I have been a runner most of my life and in the last decade started ultra marathons. Now when I run stairs or hills I can do it with the same vigour and strength as I did before. My repaired calf is about 1cm small in circumferance.

  41. humblandon 16 Dec 2012 at 4:24 pm 41

    Great advice and perspective (as usual).
    Everyone’s experience is different and unique. When I look back on it all, this was something that “needed” to happen (to me).
    I’ve been driven all of my life. In my experience, all professional athletes are driven and self motivated, to an extent which makes it difficult to come to terms with sacrifices made to a more healthy “balanced” view. This injury, and the process of rehab have added perspective and confirmation to the lip service given to the words “you can’t control everything”. Also, avenues and opportunities for growth and knowledge have opened up, as I took off the “blinders” of my insular competitive universe.
    When I woke up in the recovery room, my surgeon told me that the damage was “more extensive” than he expected (from the imaging studies). The severed tendon ends were separated by two inches and that he had to do more surgery to reattach them. As a consequence, he would not let me travel to return home for two weeks (he was afraid of complications).
    This may be why I’m experiencing this strength and function deficit at this time…It may also mean that, as I’m hoping, if I continue to work hard and be patient, that eventually it will come back…
    It’s all good. I indeed feel blessed. If the worst that happens is that I can no longer compete for a National Championship, or even play competitive tennis again, then I consider myself fortunate.
    I’m also honored to have met you, Ryan and all the fellow travelers on this road “not frequently traveled”. I’m hoping that our thoughts and exchanges help others in some small way.
    Happy Holidays,

  42. humblandon 16 Dec 2012 at 8:30 pm 42

    Thanks for sharing your experience. BTW, you sound like a serious runner. I have the utmost respect for the focus and devotion required to train for something like an ultra marathon. Also, if you read my earlier posts, you’ll see that I’m not surprised that, despite your efforts, you’re calf is 1 cm smaller.
    I hear you that the surgery is a “best guess” proposal. Clearly, there are no guaranties. My pronation issues mirror Ryan’s experience. Perhaps they could have been mitigated if the surgeon had asked about previous pronation issues, or I had thought to ask for an orthotic in the cast. Maybe they look at your feet on the table and can tell how to “fix” the tendon. I’m sure it’s as much art as science. Having said all this, I feel lucky to have had the best of care…
    From my progression so far, I have reason to believe that my repaired tendon will be at least (if not more so) as strong as the other one. At 8 months, I can run pretty well. Two miles is no problem. I can climb stairs and hike and bike fine. However, my lateral stability and “explosiveness” are compromised. From my reading, athletes who participate in sports that demand this type of movement pattern rarely attain their former level (if they even elect to try). It seems to be a career-ender for pro basketball and tennis players. The NFL studies, mentioned by Norm, also indicate diminished functionality.
    Misty May Treanor made it back to beach volleyball. It took 18 months, and by some accounts she was not the athlete she was previously (she is my inspiration). If anyone knows of another similar situation, I would like to hear about it. David Beckam had the repair. Is he the player he once was? There was an Olympic gymnast who made it back, but she could not compete at her former level…
    Now I realize that most people on this site don’t have a specific interest in these questions, or in these “outlier” athletes. They want to get back to day to day functioning and recreational sports. So, my particular situation isn’t relevant to them.
    As I said before, my glass is “half full”.
    My interest is in examining the current treatment protocol with the “cold light of day” perspective.
    As I’ve mentioned before, no one used to question orthoscopic knee repair…It took years and years of follow up to determine that it had little or no value. In fact, double blind studies showed that 5 years from the operation, the surgical group was worse off than the non-surgical group.
    I wonder if modern early weight-bearing, progressive casting and modern rehab techniques result in a similar outcome years from now…

  43. Xploraon 17 Dec 2012 at 2:31 am 43

    Eric - You have a great handle on life and this injury and I have no doubt you will manage well with the hand you have been dealt. I am not a glass half full or half empty person. If you fill it to half way then it is half full but if you drink it to half way then it is half empty. Given my way of thinking then I would also say that your glass is half full as you are only half way there and still getting better. All the best for the season to you and my other friends. Keep safe over these overindulgent festive times. Maybe better to say keep out of harms way. I don’t comment much these days but remember fondly all the great discussion I have had with Norm, Ryan, Ali(39), Barry etc. while I was on the recovery road.

  44. humblandon 17 Dec 2012 at 10:32 am 44

    Right back at you,

  45. rugby12on 17 Dec 2012 at 10:04 pm 45

    My ATR occurred on 11/10/12. I developed clots which delayed surgery. It is scheduled for this Thursday, 12/20/12. I am excited to begin my healing. I have been living with this for nearly six weeks already. I am an extremely active 57 Y.O. male. A tri guy, I have been swimming with a pull buoy for the last four weeks, walking in the pool and full weight barring now with quite the limp. I cannot do much else and now will begin laying around with my left foot above my heart. It has been an emotional roller coaster for me because of the moving target (surgery). What should I do with these last two days before surgery? I am trying to get some things done because I am convinced I will be laid up for what, two weeks? How should I arrange my bedroom area, where I plan to stay? Thanks.

  46. humblandon 17 Dec 2012 at 11:52 pm 46

    Hi Rugby12,
    Welcome to our little club.
    To answer your question, it is nice to have help, if possible. Call in some favors or ask family and friends to lend a hand for the first few weeks. I tried to keep needed things close at hand. Trips to the bathroom can be an adventure, so having a container to urinate in can save some travel time. For me, stairs were a big challenge. Try and set things up to minimize the ups and downs. Some people like the knee scooters. They are reasonable to rent and if you have an open layout, they can work fine. For me it was almost easier to have a backpack always handy to carry things. Crutches take some concentration to get used to, and you need to use your hands (hence the backpack). Also, a travel cup, that seals so that you’re not spilling liquids. A laptop close bye was a big plus for me as well. A shower once in a while was heavenly. It’s a big production with help needed, but worth the effort.
    There’s tons of information on this site. Just do a search.
    People here will step up to help, so keep checking in.
    Best of luck,

  47. kkirkon 18 Dec 2012 at 12:15 am 47

    Welcome to achillesblog Rugby. I’m about 9 weeks post-op and agree with humbland if you can get help the first week or two that would be great. I would suggest get all the chores all caught up before going under the knife and organize your house so you can minimize walking distance and have more space (for crunching around). I had to get back to taking care of business around my house ASAP and the knee scooter was great. I rented from http://www.goodbyecrutches.com . I would also get a gym sack or backpack and a shower chair for when you feel like showering after surgery.

    Finally, go out and do something you really enjoy the day before your surgery that you might not be ablw to do for a few days/weeks. make sure before the surgery to get all your questions in for your doctor (protocol, recovery, anesthesia, complications, etc……) Always get informed and ask for as much information as possible. Read the blogs and information on this site (great for support, venting, and knowledge). Keep us updated on your progress and/or make your own blog. Good luck and happy healing.

  48. ryanbon 18 Dec 2012 at 9:04 am 48

    A quick Achillesblog tip for you all: if you leave the “http://www.” off of a link, then it won’t get hung up in moderation. So, instead of pointing somebody at:


    just tell them to go to


    The link won’t be hot, but most people can figure out how to cut’n'paste it. Almost all browsers these days are smart enough to put the right leader on the URL.

    If you’re pointing to something on this blog site, then you just have to leave the http:// off. So, for instance, to point at my 100-day log:


  49. kkirkon 18 Dec 2012 at 12:34 pm 49

    Thanks Ryan. I was wondering why it was waiting moderation. :)

  50. normofthenorthon 18 Dec 2012 at 2:29 pm 50

    OTOH, I’ve been posting URLs Ryan’s way for a long time, but I’ve still had a number of recent post held for moderation — some with no URLs at all! I forget, do the Dashboard options give blog-owners the option of choosing/setting a moderation-needed threshold?

  51. rebecca4321on 01 Apr 2013 at 2:18 pm 51

    I didn’t have surgery but I had a few days where I felt the tendon mending its self (ichy feeling). It was quite early on in the first week of being in a cast.