Back to the Starting Line??

I was pretty confident that my last post, 7 months ago, would be the final time I blogged about my Achilles tendon. But, here I am with another post. Why, you ask? Well, my recovery has taken a new twist. It appears that I may be suffering from an elongated tendon.

My recovery went relatively well, but I’ve struggled to regain strength in my calf. Even after spending countless hours at the gym focusing on calf exercises along with mile after mile of running and biking, there was still very little mass to my calf muscle.

At first I chalked up the situation to the injury and long recovery time. Most information I read mentioned the recovery can take up to a year. But, I started to get more concerned when my one year anniversary came and went this past January and my calf was still weak. I decided to consult the internet for additional information. Although the information was sparse, I concluded that my Achilles tendon may have elongated at some point either during or after the initial repair.

I knew I wasn’t doing any more harm to the tendon, so before returning to the doctor I thought I would change up my exercise routine in hopes that my calf muscle would suddenly wake up. To start, I decided to stop my leg workouts and give my calf some rest. I took a 6 to 8 week hiatus from calf exercises as well as running from January to March. Towards the end of March I eased back into the calf exercises and running.

Over the next several months I noticed slight improvement, but I knew my calf strength was still not close to where it needed to be. So, in June I finally raised the white flag of surrender and set up an appointment with a foot and ankle specialist. It didn’t take long for the doctor to confirm what I had feared – an elongated Achilles.

According to the doctor, the only way to regain more strength is to surgically shorten the tendon and start the recovery process all over again. After spending a few weeks weighing the pros and cons of another surgery, I set up a date with the surgeon. I also have an MRI scheduled tomorrow so the surgeon has a better idea what he’s working with. Assuming the MRI confirms the surgeon’s diagnosis, I’ll go under the knife again at the end of July.

While I’m not excited about the prospect of another surgery and starting the recovery all over again, I also don’t like the idea of living the rest of my life with a weakened calf muscle. My intuition tells me that a weak calf muscle will probably lead to problems with my knees or back at some point down the road. So, I guess I’m considering this surgery as “preventative”. It looks like I will once again be lining up at the starting line to the virtual achillesblog marathon.

18 Responses to “Back to the Starting Line??”

  1. Tom, Sorry to hear this. I think I’m in the same boat as you are. I can barely get my heel off the ground at 1yr 3mos post op. My calf looks a lot like yours at one year and I have been having back problems due I’m sure to a weak calf. I Have always had great dorsiflexion (moving my foot up) and have been never had a range of motion problem in that direction, possibly due to a long achilles. I feel strong all the way to level (imagine standing on a curb with your toes and lowering your heel), and then noting, no pop, no lift, no strength. Near the top of a heel lift, with the other foot helping, there is about an inch where it feels like almost nothing is happening. I have to say I’ve tried EVERYTHING to get this calf stronger. I’ve gone back to pt, tried every exercise I and everyone else can think of, but to very little effect. When I hear guys say they are 90% it pisses me off (glad for them though) because at best I’d have to say I’m 50%. I chose surgery because I was told I could expect 90%, and I was prepared to be happy with this. Considering where I am, I didn’t get that benefit. I have been weighing the pros and cons in my head of another surgery for a few weeks now, and I’m still not sure what I will do. I wonder if a second surgery takes longer to heal or the chance for re-rupture goes up. I don’t know. It’s ironic that I have an appointment tomorrow with a specialist to delve into this problem. I’ll keep checking back here for updates.

    Keep us all update too!

    Jim

  2. Tom,

    It’s funny that you wrote today. I was just reading over your recovery road earlier this morning and noticed that your calf had not returned to the definition that I would have expected at the year mark - it made me question what mine would look like and if I would ever enjoy my favorite skirts again! I’m sorry to hear that your journey will be longer than you anticipated, but hopeful for you that you regain the much needed strength that you need for a full and lasting recovery.

    Good luck to you during this new path.

    Tamar

  3. Hi Tom,

    Greetings from a fellow Minnesotan and Achilles sufferer. (I live between the Twin Cities of Salem Corners and Rock Dell.) I wrote a comment to another Achilles blogger about this issue that might be useful to you:

    achillesblog.com/jgsquash/2009/05/27/worst-fears-realised/#comment-44

    Interestingly, the man I was writing also had a procedure with (one, in his case) transverse incision. Perhaps it is somehow harder to get the tendon length right in the operating room with this type of Achilles surgery?

    It is typical to have somewhat less calf power in the plantarflexed range after Achilles surgery, but with a too-long tendon, the power just disappears, because the muscle can’t shorten any more when there is still plantarflexion remaining to be done. It sounds like what Jim is saying, “Near the top of a heel lift, with the other foot helping, there is about an inch where it feels like almost nothing is happening,” although he says he is having trouble getting the heel off the ground, too, which might suggest weakness through more of the range of motion in his case.

    With a reasonably strong calf but a too-long tendon, there will be reasonable strength when your toes are up, (closer to your shin), but the strength completely disappears as the toes get lower.

    Good luck with this!

    Doug

  4. Tom - I am sorry to hear that you are considering surgery again, but I agree with you that it’s probably the right choice in the long run. Let us know if the results of the MRI confirms the diagnosis.

  5. Jim - Wow. Your situation is a mirror image of mine. You described exactly what I’ve been experiencing. Lack of plantarflexion strength, no ROM issues, and no lack of hard work or experimentation. I’ll be curious to hear what your specialist says.

    Tamar - Hopefully me latest post will give you peace of mind that you’ll once again enjoy your favorite skirts. Judging by the lack of quality info, I’m guessing my situation is somewhat rare. Unfortunately, it is one of the risks of this type of injury.

    Doug - Thanks for the info. It’s definitely later plantarflexion strength that is the problem. Like you said, the strength just disappears.

    Dennis - Looks like you might be stuck with me again for awhile. Thanks again for your continued work at keeping this site operating.

  6. Hi Tom,

    You now have me worried. I have had a similar problem after my rupture March 2008. I mentioned this to Smish in an email only a couple of weeks ago and she thought the tendon was too long and suggested I go back to my Consultant. I have not gone yet!

    My symptoms are, still very weak calf it actually feels soft and flabby, I still cannot do a heel raise (if I concentrate very very hard and try to go up on my toes I maybe can raise it by - as my husband says because he watches - no more than a quarter of an inch, and I still limp a little. Does that sound familiar? Let me know what you think.

    Annie

  7. Tom: I had to have surgeries on both of my legs to have my Achilles made longer. I had even had a rupture surgery on my right side where a regular orthopedic somehow reattached my right side too short. (He must of matched it to the other non-ruptured side which was too short.) Duh! That’s when I learned the importance of using a foot and ankle specialist for Achilles problems. Anyway, my reasoning for telling you this is that with my Achilles tendons made LONGER, I was doing single leg calf raises by about 3 months post-op on both of them. You are also very correct in saying that these issues can cause low back problems. My low back problems, which I have had since I was a kid, have disappeared since I had both of my Achilles lengthened and heel bones sanded down. It is a really crazy feeling to be walking around without any pain.

    I know how hard it is to make the decision to let someone go near your Achilles again with a knife. Once my decision was made, I found the post-op to be easier, in most ways, the second and third time. I knew what to expect and I got to pick the time and place as opposed to having my Achilles rudely choose it. You can prepare the house for several weeks of auto-pilot so the anxiety of not taking care of responsibilities can be tamed down a bit. I will say that I had trouble with being chained to the couch again. I started to loose it in that way but if you are only having one leg done it shouldn’t be too bad. Good luck and please keep us posted. I realize that choosing Achilles surgery doesn’t pay off for everyone but I chose it and it paid off big for me.

  8. Annie - The symptoms sound familiar although I’ve actually added quite a bit of definition to my calf, but there just isn’t any power or mass. My heel raise is the same as you describe. It’s probably worth going back to have it checked out. I would be curious to hear what your consultant has to say. Sorry to make you worry.

    Smish - Thanks for your thoughts. I’ve read several of your comments in the past and I know you’ve gone through quite an ordeal. It’s good to hear you’re doing much better now. I agree that it’s nice knowing what to expect this time around and also being able to prepare for the surgery ahead of time. Like you said, hopefully the anxiety will be greatly reduced this time around. Thanks again for your comments and I’m glad that you’re feeling much better now. Success stories are always good to hear!

  9. Hi Tom, Just wanted to update you on my visit to the foot and ankle specialist. I live in Las Vegas but decided to go to a well know sports ortho clinic in Southern California. The Dr watched me walk and manipulated my feet for a few minutes with me pushing, pulling, twisting against his hands and him also bending my feet in every possible direction without me resisting. And after a few xrays the conclusion was, suprise, my tendon on the injured side seems to be long.

    So what was his advice? Sorry if I start to ramble here. I told him I still felt like I was making progress in my recovery, although slowly. He said that tendon shortening is possible surgically, but he could not predict how much more heel lift I will get from the procedure (in the procedure they also take the tendon that works your big toe knuckle and attach it to your heel for a bit more power). The conclusion was to see him when I was certain I had reached my plateau, and if I could not live with the result, to talk to him then. I found this answer interesting because it was so conservative. Most surgeons seem to want to ‘fix’ you. Like the old saying goes, if all you have is a hammer, all problems start to look like a nail. He also said time was not really a factor here, and at this point the muscle may be as big as it will get because the ’sheath’ has shrunk around the muscle and it has ’scarred down’. I see where he is coming form, but this is where I differ from his opinion. In the last PT re-eval, I gained 2cm in a month, when the previous 3 months I gained nothing. So there is something happening. Also, I really feel like I have just not completely ‘let go’ still and let my brain learn how to use the muscle yet (I think this may be a big one). This is partly because I had learned how to shut off my calf COMPLETELY within a day of the injury so it wouldn’t ball up in the back of my leg (I walked around like that for a week prior to surgery). If a bodybuilder can gain inches on all his/her muscles, I think my little calf has a chance too. And finally, as the belly of the muscle increases, it will place more tension on the tendon, in effect shortening the tendon, who knows by how much, part of the reason people with big muscles tend to be a bit less flexible. No matter how much I do in the gym, I think the greatest improvement has been gained by hiking, with a somewhat heavy pack, on uneven terrain. It’s the only way I can pound it enough to get any result.

    Wen I asked what went wrong with me, and why my recovery had not gone as well as others. His reply was that it is always a combination of factors, some of which we don’t have any control over. Some tendons lengthen more than others when healing and the fibers have to ‘catch’ each other. Some tears are clean and some just leave 2 paintbrushes on each end, almost impossible to thread back together. Couple this with different rehab protocols, surgeons, how tight you calf was when you had the surgery, and it becomes hard to pinpoint what went wrong. He was very thorough and really spent a lot of time with me.

    For now I will just keep pressing on and see what happens. Knowing this option is open to me and time isn’t a factor, I will be much less frustrated.

    Keep us updated on your progress.

    Jim

  10. Jim - Thanks for the update on your latest visit to the specialist. It sounds like our experiences were very similar. My doctor proposed the same procedure with the FHL augmentation, although, like your doctor, did not pressure me into another surgery. He didn’t make any guarantees and said that he would call the surgery a success if I got back to over 80%. Although I’m not exactly sure where I’m at now (maybe 50%), I feel I could live with 80% at this point. But, I can’t stand the thought of another surgery and recovery with the possibility that I could still be right where I’m at today. After giving it much thought for several weeks, I decided to go ahead and schedule the surgery. I have another appointment with him next week where I’ll be able to grill him with some more questions and review the MRI results and then make the final decision to proceed or not with surgery.

    It’s interesting that you are still making some progress. There are times when I feel the same, and I question whether another surgery is worth it. But there are other times where it definitely feels like I’ve plateaued for the last 6-9 months. Perhaps it’s mentally as much as physically, but I feel like I keep giving it my all every time I workout and my calf just doesn’t want to respond. My doctor didn’t really give me the sense that I could expect any more gains without the surgery. In fact, I kind of got the impression that, without continued exercise, the calf could atrophy.

    You’re doctor’s reply to you “what went wrong” question was pretty much what I had been assuming. I’m curious to know if there was something I did during the recovery which lead to the lengthened tendon so that I can avoid that if I choose the second surgery. But, like your doctor said, it was probably a combination of factors and it’s been pretty easy for me to accept that.

    Thanks again for sharing and good luck with pressing on. Hopefully you’ll continue to see progress and avoid another surgery.

  11. Sounds good Tom. I feel like I just got a third opinion! What I can’t wait for is to stop thinking about this damn leg, and whatever level of function I get back, just accept that as normal. I want to be at peace like that 3 legged dog that doesn’t know anything is wrong, it just is what it is.

    Keep firing away with the updates.

    Jimbo

  12. Hi Tom, I have eventually been persuaded by my husband to get my achilles checked out again. He has just telephoned me from Lancashire County Cricket Club after speaking to the physiotherapist to the England Cricket team. He has made an appointment for me for Friday. He said it did sound as if the achilles was too long but would advise me of the best course of action he said there might be an alternative to a second operation, I really hope so.

    Have you decided to go ahead with your operation?

    Annie

  13. Annie - Thanks for the update. You’ll have to let me know how your appointment goes. I met with my specialist again yesterday. I’ll probably post more details in the blog when I have a moment. As of now I’m scheduled for surgery next week. There is still a part of me that’s hoping for some miraculous strength gain or to find an article about a revolutionary technique for shortening the tendon without surgery, but I’m not holding my breath. I’ve perused the internet for hours and have found very limited information regarding treatment of an elongated tendon. The couple articles I’ve read seem to imply surgery is the only way to get strength back. I believe I did see one article that mentioned functional bracing was an option, however, the results were poor. I hope this doesn’t sound like I’m in disagreement with the physiotherapist your husband spoke with or dampening your spirits. I’m just wishing there was more information or options available.

    Good luck with your appointment. Let me know if you find out there is an alternative to another surgery.

    Cheers,
    Tom

  14. Hi Tom,

    Just posted a new update on my blog, and you can read my bad news on there, looks like we will both be back to square one soon.

    Annie

  15. Tom,

    Hope you are recovering well from you 9/8 AT shorting surgery. Watch out on the medication they give you.The stuff they gave me sent me down a terrible path of mode swing and sometimes I can still feel it now.

    It has been 5 months since my repair surgery, and the recovery has not been as good as I wanted. I feel my calf is actually still shrinking. I have noticed that my AT has thickened, about twice as thick as the left foot. Is this an indication I am heading down the path of elongated AT?

  16. Steve - Sorry to hear you’re not where you’d like to be with your recovery. At 5 months it may be a bit premature to assume an elongated AT, but it’s probably worth discussing with your doctor. The thickened tendon isn’t an indicator as that is just scar tissue from the injury. It may diminish some with time, but it will probably always be thicker than the uninjured leg. The biggest indicators for me were lack of plantarflexion strength and too much dorsiflexion. I was never able to get much rise on a single leg heel raise even 18 months after the injury. I could only momentarily get my heel off the ground. As for dorsiflexion, I noticed that when I laid on my back and stuck my legs straight up in the air, the toes on my injured foot dropped significantly more (closer to shin) than my uninjured foot.

    As I mentioned, it may be worth it to speak with your doctor/surgeon. I’m not sure what you’re doing for exercising, but you may want to try changing up your normal routine. Try some new exercises or maybe give your calf a rest if you’ve been going through hard workouts. Are you able to do a single leg heel raise? If so, I would do them as often as possible. You could also try walking around on your tiptoes.

    I hope you start to see some improvements soon. Good luck and let me know if you have other questions.

  17. so you were able to run and do leg lifts???? just no muscle growth???? what about a limp???? lifting power????

  18. Blog worth reading for achilles elongation..

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