Going Immobile

So at my wife’s urging, we joined the local swim and tennis club last summer.  It’s been a great place for the kids (ages 7 and 4), but in order to justify the cost, I want to take advantage of as much as it has to offer as possible.  I had never really played tennis before, but I figured since we now had easy access, it could be a great sport to learn, especiallysince there seem to be a lot of older folks enjoying it.  Besides, just going to a gym to get my exercise has never held my interest for very long.

So about six weeks ago I learned that the club had regular Wednesday night clinics for its 3.0 (adult beginner) players as well as a team that plays weekly matchs.  Gerat fun!  I’ve been picking the game up pretty quickly, and two weeks ago I played myfirst doubles match… and won!  Last Saturday was my first “away” match.  I had served up 40-15 in the third game, having lost the first two, when a the opponents return came back about 10 feet to my right.  I turned and took couple  fast steps setting up for a forehand when a sound like a gun went off and I felt like I had been shot in the back of my right leg. just below the calf. Down I went.

At first my toes were numb, and one of the guys on the other team, who turned out to be an ER doc, had me push my toes against his hand, which I was soon able to do.  I was helped to my feet, and given a beer.  Although I immediately thought I may have an ATR, the ER doc for whatever reason didn’t seem to think so.  He was the same guy who was also speculated that I may have hit back of my leg with my racquet as I was going for the shot.

 I was hoping I just had a pulled or torn the calf muscle. I could “walk” by putting my right foot in front and the following behind with the left.  But there was no way I could roll any wight onto the front of my right foot or push off it.

A teammate who I had carpooled with drive me home and I took up residence on the TV room couch.   I called the advice line for my HMO. The first  nurse I spoke to  suggested R.I.C.E  (Rest, Ibuprophen, Compression, Elevation).  By the evening, it was apparent that that helpd the pain, but I wasn’t about to walk it off anytime soon.  I called the advice line again and was able to make an appointment for a telephone consulation with a doctor the following morning.

The next day was Father’s Day, and my condition hadn’t changed.  The M.D. I spoke with wanted me to come in for an exam.  Rather than taking the immediatelyavailable appointment, I elected to wait until the afternoon, so that I could have a Father’s Day brunch with the my children.   The whole family drove me to the appointment (Kaiser Permanante San Rafael), but I had them drop me off rather having to wait around with me.   I thought they would be picking me up in an hour or so.

The moment of truth came quickly.  The doctor did the Thompson’s Test.  (I guess I should not be surprised that the ER doc on the tennis court didn’t think to do it).  She squeezed my left calf, and my foot immediately pointed downwards.  Then she showed my how my right foot didn’t move at all when she squeezed the very sore calf on that side.  She stepped out to telephone the orthopedic surgeon on call.   When she came back into the exam room with him onthe line and asked “When was the last time you had anything to eat?”  I knew it couldn’t be a good situation.

About 45 minutess later, the surgeon arrived from San Francisco.  Due to the large brunch, I really hadn’t eaten much of anything, and the O.R. was open.  I had a spinal anesthetic and he stiched the tendon back together.  Meanwhile, I began trying to figure out how I was going to manage without being able to drive for the next six weeks as the full implications of what an ordeal this is going to be come to light.  I’m sure I don’t need to tell this audience about that.

So it’s now been one week since the tear and six days since the surgery.  I have barely left the TV den.  Hurray for the internet, beacuse I have this net book which I can use to access my work computer files, and a phone which is a clone of the phone that sits on my desk in myoffice in San Francisco.  Hip, hip hurray for the World Cup and Wimbleton, the past week’s entertainment.  I guess if you are 25, it’s more lile;y that you play an eleven hour match without hurting yourself.

10 Responses to “Going Immobile”

  1. Sorry to hear you ruptured your tendon. There do seem to be a fair number of tennis players here, as well as other racquet sports players. As you will soon learn here, it’s too bad they rushed you into surgery as if that was the only choice. Did you give you the options or explain everything that can go wrong with a surgical repair? I’m the poster boy here for surgical complications and there is no way that I would ever agree to surgery again if I either re-rupture or rupture the other tendon. Are you in a cast or a boot? I never had a cast until my fourth surgery and then only for a week. Some people get a cast and some get a boot? What is your surgeon’s plan for getting you to full weight bearing? My plan, until it got derailed, was stitches out and partial weight bearing at 2 weeks plus begin physical therapy, full weight bearing at 4 weeks and into 2 shoes as soon after that as I could tolerate it. My surgeon told me there was no evidence that prolonged immobility and non-weight bearing accomplished anything except more muscle atrophy. My current therapist told me that within 24 hours of the ankle being immobilized the calf muscle starts to atrophy. Keep us posted on your progress.

  2. Right leg and 6 weeks of no driving?

    I didn’t drive for 3 months!
    I got a ticket the 3rd week of driving because I didn’t stop on time.

    Work something out with your employer and rest!

  3. ask your doctor via email (I’m with Kaiser in San Jose too) about your recovery protocol.
    when stitches will be removed? when cast be changed to a boot and what kind and for how long? when PT will start?
    yes, it may be 2 months till you drive a car again, but time flies fast.
    enjoy your immobility while you can ;-) watch TV, browse inet
    as when you’ll back on your feet you’ll need to catch up with many things and that when you say good by to TV and much sleep. May be I’m rude about what I wrote - you will recall it in 4 - 6 months with a smile ;-)

  4. Like Gerry, I’m one of the local cheerleaders for avoiding ATR surgery. Unlike Gerry, I actually avoided it THIS time, after having successful and uneventful surgery on my other side, 8 years ago. But that decision is “bygones” in your case now! (But if any of your pals or relatives ruptures an AT, send them to my blog for links to the evidence that the surgery adds no benefit to the boot!)

    It’s definitely not fair that the people who are most likely to suffer with this affliction are the ones who are doing the Right Thing from a general health and wellness perspective, staying active and getting a good workout in sports. Not fair at all, but it’s the fact.

    After my first ATR, I returned to the brutal sport that tore it — competitive volleyball in my case — knowing that there was a real risk that I’d end up tearing the other one, too. It took 8 years — 7 great seasons after my recovery — but it did happen. Thanks to the lack of surgery, the much faster rehab protocol, and knowing where I’m headed, I’m finding this recovery much more pleasant than the first one.

    I’m 6 months in now, and I’ve returned to all my normal activities except the high-stress AT-intensive ones like volleyball. Mostly I’m bicycling to the sailing club and sailing a lot, and biking home. I do recommend returning to active sports activities even if they put you at risk on the other side, though lots of recovered ATR patients understandably decide to go easy afterwards.

    If your Docs haven’t given you a clear road-map of your rehab steps for the next few months — when you start Physio, when your ankle position moves to “neutral”, when you’ll be partly and then fully Weight Bearing, when you’ll get out of the boot (You did get a boot and not a cast, right?) — then you should insist on getting one, on paper. The one I’ve followed, which produced excellent results in a randomized trial, with both surgical and non-surgical patients, is buried on my blog page. (Look for “A more complete review of the options — surgical vs. non-operative” then search the comments for “protocol” and you’ll find the link. If not, ask here and I’ll post it.)

    I don’t think there’s any excuse for any ATR patient to go more slowly than that protocol, and it is probably bad for your recovery to do so. Prompt return to Weight Bearing seems especially beneficial, as is prompt (unweighted) mobility, like gently exercises and PT. (That’s one reason why the boot produces better outcomes than casts.)

    A prompt transition to the neutral position (more prompt than ~6 weeks post-op) has NOT been shown to produce superior outcomes, as far as I know. And getting into “2 shoes” faster than around 8 weeks may have benefits, but also has risks. I like hinged boots, and so do the meta-studies (which usually call them “functional orthotic braces”!!), though the study that produced “my” protocol didn’t use them. (It was sponsored by AirCast, a manufacturer of NON-hinged boots — and God Bless them for sponsoring a great study, too!)

    Good luck, and good healing, and post some details of your protocol if you have any.

  5. Thank you for all of your input. I am nearly 44 and it is my dominant right leg that suffered the ATR. Surgery was presented as the best option, because it was a complete rupture, and my surgeon wasn’t confident, even with pointing my foot in a cast, that the ends of the tendon would find each other and reattach. Perhaps the fact that the rupture is as near to the calf muscle as my heel had something to do with it.

    I am in a temporary cast, and have been told that I will get a fiberglass cast in another ten days after my incision(s) are checked. I ws told that I will be non-weight-bearing for six weeks, hence the no driving. I have assumed that once I get a boot after the fiberglass cast comes off that I’d drive somehow, but not being able to flex my ankle could still be a problem, I suppose.

    Apparently, the P.T. is not supposed to begin until after I am in the boot, so it sounds like my surgeon has envisoned an old style of rehabilitation. I will be seeing someone different in ten days, so perhaps the more modern program can be discussed.

  6. tennisnewbie, there are two issues here that have been addressed with Evidence-Based Medicine studies, and I’m afraid your medical professionals haven’t gotten the memos on either! So it’s unfortunately part of your job to educate them, for the sake of your own healing, and as a favor to the next maybe 100 or so ATR patients that go through their care.

    The first issue is water over the bridge. Almost everything they told you about the benefits of surgery has been proven wrong in FOUR recent studies, all randomized prospective trials of good quality. All dealing with TOTAL ATRs (”a complete rupture”), the kind your surgeon thinks surgery produces better outcomes — Just Plain Wrong, check the EVIDENCE!!

    (Your ATR may have been higher than average, closer to the calf muscle. Several bloggers here have been REFUSED surgery on that basis, because their surgeons told them that a high tear made then WORSE candidates for surgery and BETTER candidates for non-surgical immobilization! I don’t think there’s any good evidence either way, and the randomized trials did not exclude higher-up ATRs, so they’re part of the general evidence.)

    Your surgeon may lack “confidence” that the two ends of the tendon can find each other and heal together at the right tendon length — I admit it seems “magical” that it works so well, and so consistently — but the studies all tested for ROM (a function of tendon length) and found that the non-surgical patients did just as well as the surgical ones in that measure — and in strength, too, about which many falsehoods are repeated in support of surgery.

    But that’s all water over the bridge. What’s NOT water over the bridge is your own care, post-op, which is obviously not well designed to optimize your healing, or to make your life easier, either. Dennis has posted a bunch of links to good studies and meta-studies here, that compared the results of quicker and slower protocols after surgery. NONE of them showed any benefit from being “non-weight-bearing for six weeks”, and most of them showed statistically significant clinical DISbenefits — not to mention the nuisance, inconvenience, and accident risk from being on crutches that long!

    Some of them showed benefits from IMMEDIATE weight-bearing, right after surgery, in a hinged boot (which the studies call a “functional orthotic brace”, just to confuse us!). Of all the factors, early Weight-Bearing seems to be the most important one, in improving clinical outcomes, though early mobility (boots instead of casts, with early PT) is also clearly proven to be beneficial. (I haven’t studied those studies carefully, because they didn’t apply to my situation, but you should.)

    The four recent studies that compared surgery to non-surgery produced excellent outcomes BOTH ways, and used the SAME protocol on both kinds of patients. That protocol (which I followed happily without surgery, as did mikek753 and gunner here) is MUCH faster than yours! If anything, the stitches holding your tendon together should let you go FASTER than we did, and the studies all show that faster is better (though presumably not without limit).

    That study protocol has no casts, just a boot (a fixed, non-hinging boot, unfortunately). Non-WB lasts only TWO weeks, partial WB for only another TWO weeks, then Full WB “as tolerated”, starting at FOUR weeks post-op! It moves to “neutral position” at 6 weeks, and “Wean off boot” at 8 weeks.

    You should talk to your health professionals about evidence and protocol choice, and “encourage” them to treat you in a way that has been proven to work well. There is an argument for going faster than that protocol; going slower is just bad medicine, given the evidence!

    One of the challenges for an ATR patient is that there are no ATR specialist surgeons. Every surgeon learns how to do ATR surgery — it’s been called “the tonsilectomy of the leg”. it’s a minor sideline, when you’re not doing surgery that’s more difficult or more important. So the average surgeon doesn’t even take the time to read the literature about ATR rehab protocols. And what all current surgeons learned in Med School has — mostly since 2007! — been proved wrong by a number of scientific studies.

    If your surgeon’s ATR treatment were a car, it would have been subject to a mandatory recall, and retrofitted with the new version. If it were a drug, it would either be taken off the market or accompanied by big warnings in big type.

    Unfortunately, the medical establishment and the (world’s) governments have no procedure for retro-fitting a surgical-and-immobilization protocol that’s been tested and found harmful, or much worse than the best version. That’s why you’ve got the job, to fix this sticky accelerator pedal. Sorry about that!

    If you’re tempted to just ride along with it, figuring that your ankle will probably heal OK, don’t forget the next patient, who will get funneled into exactly the same treatment you got funneled into. . .

  7. tennisnewbie,

    Get informed and make your own rehab decisions - it’s YOUR foot after all. I chose surgery because I wanted a guarantee that the ends of the tendon found their way together even if the risks were a bit higher. No infection but I did get an adhesion so I did pay a small price. My doc is a well respected surgeon and I am satisfied with “our” procedure but I don’t care for his rehab protocol and he does not care for mine. I am going my own way for rehab and PT and I suggest you do as well since both our docs seems to be stuck with classical protocols.

    You might inquire about a splint instead of a full cast. I had 2 post-op splints for 3 weeks with the change at 2 weeks for suture removal. While splints are not usually intended to be removed at home, they can be if your incision gets wet and can be replaced after changing your bandages. They are also very comfortable if fitted properly and are self adjusting for swelling if applied with an elastic “ACE” bandage.

    Once in a boot you are free to rehab either on your own or follwing doc’s or PT’s orders. Right NOW you have time to order the exact boot you want from any number of online providers. If you are in a splint you have the option of cutting it off at home and switching to the boot whenever you feel ready (probably 2-4 weeks). I ordered a knee roller before surgery and wish I had ordered my favorite choice of boot as well. My doc would not prescribe my desired hinged boot so I’m stuck with his fixed boot. I expect to be out of the boot soon so ordering a hinged version now doesn’t make much sense. Getting into a boot early also allows massage treatment of adhesions ASAP. Releasing mature adhesions can be quite painful!

    Good luck!

  8. Norm -

    Your post was as much of a blow to my head as the ATR was to the other end of my body. Since reading it, I have been exploring the blog site more deeply and came across the extensive writing that you have done on the issue.

    As you said the decision to operate or not is water under the bridge for me. Frankly, I can’t recall whether the location of my rupture was factored into the cut or not to cut decision. I do recall that there was some mention of increased likelihood of scar tissue and re-rupture without surgery. Regardless, that ship has sailed.

    However, I have printed several of the articles regarding rehabilitatino protocals that have been linked to the site and the overall impression that I get is that, in the long run, the results from early weight bearing vs. non-weightbearing seem to be the same, but the quality of life during rehabilitation is greater with EWB. Since I am self-employed and my office is 13 miles away, and I have young kids and summer plans, being able to ditch the crutches asap is important.

    So even though my next appointment isn’t until July 10, I am going to try to get an appoinment earlier and, armed with the various articles, attempt to get a boot this week. Failing that, I will put up a fight on July 10 before I let them put a rigid cast on me. If the AAOS recommends protected weightbearing at two weeks, (even if the recommendation is “moderate”) I should be able to get my way.

  9. no, you will NOT drive in a boot - it’s just to wide.
    Some tried to drive by left foot, but that’s risk.
    Think from long term - if you postpone your driving for 2-4 weeks till you are in shoes, but will not get in any accident as result.
    While I was in my boot I changed it to shoe in car and drive - very slowly ;-)
    than back to boot and walk from my car
    I sit in parked car at 1st for an hour pressing pedals that tried drive on safe road and only the next day went on 101 and etc.
    I even didn’t try left foot as in extreme situation your brain can be slower than your spine and left foot can’t act as should.
    as already mentioned get all details from Doc.
    Did you try to email your Doc? there is option to do it at kaiser web site.

  10. I haven’t pored over the early weight-bearing post-op studies the way I’ve pored over the surgical vs. non-op ones, and some of them definitely show identical results rather than better results with early WB, as you say. But I’m pretty sure that some — including the 2005 meta-study that I cite on my blog — showed superior results from very early WB with the “functional orthotic brace” (aka “hinged boot”!).

    Either way, if you can carry stuff around weeks or a month earlier and have “only” identical clinical results, why would anybody do anything else??

    8 yrs ago, when I tore my right ATR, I definitely drove around in 2 shoes for the 9 days before surgery. I used my heel for the pedals, esp. the brake. It seemed safe enough.

    After the surgery, I was NWB for WAY too long, no driving for me. After I got into a “walking cast” then a (hinged) boot, and became FWB, I think I did resume driving, in our stick-shift car. (Whether that was the smart thing to do or not is another question entirely.)

    My Donjoy MC Walker boot was narrower than the AirCast (fixed) boot I got this time. And the AirCast was on my left foot this time, and we’ve switched to an automatic transmission, so I definitely drove this time, but my injured leg was just along for the ride, not driving.

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