Week 5 Post-Op: VACOcast, PT, PWB and the “Small Achilles”
May 21, 2014 by texasflyer
Currently at 5 weeks and 1 day since my surgery. Overall, I am feeling much better and much of it has to to with PWB.
A quick run-down; I was in a splint/soft cast for 3 Weeks post-op. Then, stitches out, into a VACOcast and further NWB for 2 more weeks. That meant 5 weeks total post-op NWB.
VACOcast: Initially, I found the VACOcast to be a b*itch. I was rather unhappy with the fit at 20º, the second strap was just putting too much pressure on the top of my foot, which is a little bony in that area. So a portion of the top of my foot was pretty severely inflamed, I tried putting some cut up fleece on top and under the plastic of the boot, but the damage was mostly done! After some long work and travel days, I started to get pain and moved the boot to 25º, which not only helped the fatigue and Achilles pain but also position the boot in a different manner so the top of my foot got a relief.
First Physical Therapy Session: At 5 Weeks I had my first PT appointment and it went ok. Apparently, I hadn’t kept my leg straight often enough during my 5 weeks post-op and now I can’t stretch my leg straight out entirely to where the back of my knee can touch the floor. It’s an odd feeling and perhaps should have been obvious during my recovery. But I did have some decent pain the first couple of weeks and all I could focus on was simply getting comfortable. That meant having my splint elevated and my leg slightly bent to take pressure off my legs, knee and calf. No one told me to keep it straightened out and work in some light quad/hamstring stretches during this period. Maybe shame on me? !
So the PT was concerned that I was going to have a pretty decent haul for recovery given that my Achilles ROM and flexibility was rather low too. I should note that I waited 18 days post-injury to get surgery, so I will have been nearly 8 weeks NWB. I will admit, the PT session was a bit scary given my 8 weeks time and I was apprehensive to push my Achilles too much, particularly in the straight-back stretch! At home, I’ve able to concentrate much better on these exercises and now am able to see some teeny, tiny improvements in just 2-3 days. My Physical Therapist recommended that I have 2, if not 3, PT sessions per week as they deemed I might be a little behind the curve in recovery.
PWB Finally!: Going PWB (as tolerated) with crutches was the saving grace at the PT appointment. Wow, what a difference. I’m actually slower now that I was at NWB on crutches, but that’s ok. I love being able to finally feel my body/ankle/Achilles, let it respond and go accordingly. When I put just a bit too much weight on it, there’s definitely a deadness/dullness sensory along a major tingle in my heel I think telling me to reel it in a bit. I’ve started walking about 30 minutes each day in addition to my ROM exercises 3x per day.
The "Small Achilles": Lastly, I was very frustrated at 3 weeks and being told still NWB for 2 additional weeks. I realize many (most?) on here start PT and PWB at 3-4 weeks. I was wanting to follow the University of Wisconsin protocol as it was recommended to me by a family member who is 10 months ATR. I sent the protocol to my Dr, PA and future PT at the time and voiced my frustrations. They came back and basically said that they do indeed like to start PT and PWB in most of their patients at 3 Weeks, but not me.
Given the severity of my injury, the fact that I walked on it for 5 days post-rupture, waited 18 for surgery, my age, desire to return to action sports, physiological makeup, they wanted to wait with me. They also stated that I have smaller than average Achilles and that was a major factor. I found this interesting and was a bit skeptical as all I wanted to do was start PT and PWB! But they said the size and diameter of both of my Achilles is smaller than the typical male’s and one for my size (6ft, 200 lbs), thus keeping a more conservative protocol. I have always noticed (or thought) I had pretty skinny Achilles along with skinny legs, ankles. So I did understand, to a degree. They said it was entirely genetics, wasn’t actually too uncommon and that it still didn’t contribute to it tearing. There’s also no real concern that there’s that much more of a propensity to tear again (or in my good one either).
My Ideal Timeline: According to my PT, they want me to be 0º in one month from the start of PT/PWB/Week 5. That means lower my degree of VACOcast 5º per week. 20-15-10-5 in 4 weeks. I think this sounds positive and then, if all goes well, I could get into shoes with a heel lift. But all of this is going to take solid PT and home-exercise work on my end.
But everyone is correct, going to PT and PWB is a huge confidence boost and while I had to wait 5 weeks post-op (8 weeks total), I can halfway imagine walking normally again!
10 Responses to “Week 5 Post-Op: VACOcast, PT, PWB and the “Small Achilles””
Congrats and Yay!
I wonder how much your “physiological makeup” had to do with their holding you back so slow so long - like did they fear you’d go faster than they said to?
And I wonder if anybody besides me wonders if your tight hamstrings and knee is mostly the result of holding your foot in the air for 8 weeks while crutch-walking instead of putting it back on the ground a few weeks sooner.
Finally, when the evidence shows that large random cohorts of ATR patients heal as well OR BETTER going much faster than you’ve gone, with OR WITHOUT surgery, I wonder what the supposed scientific or evidentiary basis is, for supposing that people with thinner than average ATs would respond in the opposite direction.
And congrats on solving the boot-fit problem, too! I think many simple solutions to these problems work if you apply the fix BEFORE your leg gets scraped or bruised or otherwise injured by the misfit, but it takes an even better solution to work after your leg is sensitized by it.
Thanks Norm,
Yea, I pushed, prodded and supplied a few studies. All of which they were familiar with but they also stated that these studies don’t show the age/sex/physiological factors of the patients. I think that’s correct, for the most part. Therefore, they wanted to be extra cautious with me. I think since I’m a bit on the young side of it (31) and again given my “small Achilles”. I also wonder what they saw once I went into surgery. If collagen or healing had begun to occur after 18 days and they basically had to undo all of that. Also, they stated my ankle/foot makeup, which again I’ve always thought were pretty scrawny, for lack of a better word, to the rest of my body makeup, which I carry most of my weight up top, big chest, shoulders and long torso. I’ve had a history of ankle problems, mostly just a propensity to sprain them, but also have fractured both ankles, of which they still said didn’t have to do with my ATR but I think lends itself to wanting to be conservative in this current rehab.
They do seem to be a pretty progressive operation and want me in shoes (with a heel lift) in 4 weeks from now (4 weeks from first PT). There’s not much I can do about it now anyways, I waited until Week 5 and now I’m really starting to see improvement. My leg-straightening is nearly fully flat now after just a few days of exercises.
I guess you may as well have full faith that they know exactly what your leg needs, tf. From my vantage, I think they’ve got the mathematical sign backwards, and what they call (and what everybody USED to call) “conservative” - I.e., slow and safe - has now been shown by a tonne of evidence to be slow and somewhere between risky and just useless. Nowhere near as risky for surgical patients as for the non-op crowd, but there are NO studies showing risk-reducing benefits from going slower than UWO or Exeter or Vaco or Wallace, all of which have gotten great results with low rerupture rates with a random distribution of leg scrawniness!
Every OS and clinic can have impressions or theories, and most of the impressions and theories from 10-15 years ago have now been conclusively proved wrong. But many of them persist, just because that’s how humans roll… and most patients assume there’s some occult wisdom operating, that trumps the best scientific evidence. One hilarious BMJ article called it Eminence-Based Medicine!
You’re right, “conservative” only used to mean slow and safe - so it’s interesting (well, just a little) to note that at Exeter, it’s quoted conservative rehab protocol means fast and safer, and is the same timeline for op and non-op.
They use the term simply to mean non-op, no knife. I’m a hill and mountain walker, had a complete rupture, enjoyed a full recovery. Key is the need for early physio work and increasing mobilisation after 2 weeks.
Norm, or anyone else…
I found a few threads late last night while reading up on this blog regarding early dorsi stretching and that it’s either non-essential, not preferred or can be limited. Care to elaborate?
I was told by one PT to use a belt/towel and do dorsi stretching of Achilles for 15 second holds, 3 sets, 3 times per day. My second PT did not recommend this and instead has me doing simple “ankle pumps”, then along with ankle circles, left-rights.
I have to admit any resistance or real stretching of my Achilles in dorsi-felxion is not only scary but it’s just super stiff. And it just doesn’t feel right. Not sure if I’m being a huge wimp or what!
TF, I’ve generally been a DF stretching wimp, for myself and others. I did less of it than my PT prescribed, and I still healed a but long in the AT-Gastroc system. BUT, while healing long is a very common cause of frustration and strength or even functional deficits, healing short can also cause problems which can be very serious - see my page on that topic.
Surgeons very often shorten ATs, often 100% intentionally, and non-op hardly ever does.
A lot of ATR Rehab seems like a tightrope, with equal perils on both sides of Just Right, but most of it is asymmetrical. This one is pretty tightrope-like!
SO,… If you think you’re at more risk of healing long than short, be a wimp on DF stretching. If vice-versa, then go for it!
Since the two heads of the calf muscle (Gastroc and Soleus) attach separately to the AT, one can be long when the other is short. RyanB and I both think we healed a little long to the Gastroc but Just Right to the Soleus. Since the G is engaged in straight-kneed heel raises (etc.) and the S in bent-kneed, one could stretch one aggressively while being a wimp with the other.
Aye, thrown for a loop, here. I’ll have to read up on healing long and short this weekend. What should I be aware of in relation to this at 6 weeks post-op, PWB 1 week and into my 3rd PT appt next week?
I would read up, it’ll stand you in good stead. It might also help to ask your OS if (s)he intentionally trimmed your tendon ends back to help prevent you from healing long. Mine (back in 2001) freely admitted doing so. And it seemed to work great until it gradually contributed to knocking my right knee out of alignment. Now the knee seems fine as long as I stretch that calf and hamstring CONSTANTLY. (And my podiatrist is worried about my smaller foot joints.)
Some post-op patients do heal long (like RyanB & MANY others), but others end up short like my first ATR.
I’ve never heard any convincing explanations about how aggressive, weighted or passive df stretching does any good while the AT is still healing and rebuilding. It’s hard to believe that actually making the AT longer than the surgeon did — you know, STRETCHING it! — is helpful. Sure, you have to expose it to a regime of increasing loads as it rebuilds, but that’s more exercise than stretching. I’ve heard of “frozen shoulder’, but not “frozen ankle”. If the purpose is to lengthen the calf muscle (which has been partially contracted for weeks), can’t we do that AFTER the AT gets stronger?
There’s also no conclusive evidence that early stretching — either intentionally or accidentally — is the cause of healing long, though it sure seems logical. Heck, we don’t really understand yet why the vast majority of pre-Wallace non-op patients end up with good tendon length, judged by strength and ROM.
Hi norm,
I don’t know if you are still checking this site, if you are I have a few questions.
I ruptured my achilles on jan2nd 2016. Went to er and was put in a splint. On Wednesday I saw orthopedic and we decided on no-surgery. I’m very happy with that decsion. Ortho then put me in a boot on Jan 1399th. He wanted me in a cast but I said no and actually brought a vaco cast boot to the appointment. My issue is he wants me no weight bearing until I session January 27th. He also believes that no pt until 8th week. My fear is that it’s too conservative. My doctor does not seem to be open to other options and I’m feeling lost. The wallace study does seem like a good way to go but how do I do it without his approval.
A little background I’m 58 and I hurt it playing pickleball. I’m not an athete but I do like to walk , dance and swim.
Thank you,
Karren
Karen - if you are after Norm then you will need to drop a line to his page (Normofthenorth). To answer you question from my perspective, you have been an advocate for your own recovery and that it great. It is your body so if you would like to go down a more modern route then you could find another doctor who is willing to listen or work with you. Since you have not had surgery that should be much easier to do. Wallace, Exceter and UWO in Canada all have good protocols which are slightly different but the key is getting you weight bearing early. Also some gentle movement early is recommended and all this starts about the time you are at. I am not sure where you are from but in Aus we can go to a PT any time. They will still be reluctant to go against any doctor you are under but if you sack your doc then there is no conflict. You can follow a protocol on your own but if you do not understand things it could be dangerous so I would always recommend you seek some advice from a hands on medical expert. Conservative treatments for this injury have been shown to increase the chance of re-rupture.