Healing Long - 2+ Years Later

26 Months 13 days Post Op #2

It’s been a year since my last post and 3 years and 10 months since my initial injury and surgery.  I still check in at achillesblog from time to time, but generally leave the commenting to the newer crop of rupturees.  I decided to add another post because I notice the “healing long” topic comes up every few months, and I know there aren’t many resources available for reference.  So, as one who “healed long”, I’m including an update to give a long range perspective now that it’s been over two years since I had a second surgery to shorten the tendon.

Life is back to “normal” in the same way it has been for the last year.  The injury is still a part of my life, but it doesn’t hold me back from doing or trying the activities I enjoy.  Running continues to be my main source of exercise and I completed another marathon earlier this month, my second since the injury.  I finished up a few minutes faster than last year, achieving my main goal, and just a minute off my personal best.  I can’t help but think that I would have cut several more minutes off my time if I wasn’t still trying to overcome this injury.  Aside from a break during marathon training, I still work on strengthening my calf which continues to be the main shortfall of my recovery.

The rehab from the second surgery has lasted much longer than I ever imagined.  My surgeon did warn that it could take 18 months, but of course I felt like I’d be back to normal within a year.  18 months passed and I was still concerned/disappointed with my recovery.  I made some slow progress, but my calf strength was still lacking and I was dealing with some nagging tenderness in my heel.

Eventually I decided to meet with a new ortho just to seek a different opinion.  I was fortunate enough to get in contact with a foot & ankle specialist who was not only familiar with achilles reconstruction as a surgeon, but also as a patient.  Dr. C had chronic issues with his ATs which eventually required surgery a few years ago.  He had lengthening issues in both tendons following surgery, and eventually had shortening surgeries performed on both legs.  One leg even required a third surgery.  My appointment with him was very surreal.  I felt like we were a couple of war veterans swapping combat stories.  Unfortunately, I got so caught up with talking to him as a person and fellow patient that I forgot to ask many of the medical questions I had such as, “What can cause a tendon to heal long?”.

After comparing calves and recovery stories, Dr. C described a tendon augmentation surgery that could improve my situation.  However, he quickly recommended against such a surgery as he felt the potential benefits were likely to be minimal and not worth the inconvenience of another surgery.  Hearing a surgeon recommend against surgery just about knocked me out of my chair, but it made his opinion that much more valuable.  At that point I felt I had explored all my options, and determined that time and continued strength training were my best options for getting closer to 100%.

It’s been 6 months since I met with Dr. C and I’m happy that I continue to notice some small improvements.  My right calf is still weak when compared to my left leg, but it is better than it was earlier this year and definitely better than it was prior to the second surgery.  The tenderness that I constantly felt in the tendon finally dissipated within the last few months and my ankle movements feel more fluid and natural.  I still struggle a bit with single leg heel raises.  I can’t quite get the last bit of push to really extend up onto my toes.  I’m able to do so if I cheat a little bit and use my finger tips to help with balance and offset a bit of weight, but still a bit weak. My running stride is also a little weak and I still feel I’m recruiting other muscles to offset the lack of calf strength.  But, this too is better than where it was 6 months ago.  I may try some different things with my stride, such as shortening it, now that I’m done marathon training for awhile.  We’ll see if that makes any difference.  In the end, I think it just comes down to calf strength.

So, where do I go from here?  The last few months have been encouraging even though my calf is still not as strong as I’d like it to be.  It’s good to know I’m still making progress given that the second surgery was over two years ago.  I’m somewhat resigned to the fact that a 100% recovery is not in the cards for me, but it doesn’t mean I can’t continue to move forward.  If I had to guess, I would say I’m somewhere around 75-80%.  As I mentioned earlier, the missing strength doesn’t keep me from doing anything I want to do, but I’m not able to do things quite as well as before the injury.  I can’t jump as high or as long, but I can still jump.  My running stamina may not be as strong, but I’m still able to run long distances.  So, overall I can’t complain much.  The last goal I’d like to achieve is to get to a point where I don’t think about my calf or tendon when attempting to jump or hop on my right leg.  Hopefully that happens soon.

Healing long seems to be a poorly documented and/or understood complication of an achilles injury.  Fortunately for those concerned, I’m sure the main reason for the lack of information is the infrequency of the condition.  It is something to be aware of during rehab, but hopefully not something that creates any more concern than the injury itself.

11 Responses to “Healing Long - 2+ Years Later”

  1. Fascinating & helpful (& mostly positive) update, Tom, and beautifully presented, too. Thanks for sharing, and keep getting stronger!

  2. Hi Tom, like you not checked in for a long time and there you are. I never did go ahead with the second surgery, I just tolerate not being able to even break into a jog, achilles still extremely tight and quite hard despite all the various physio’s hard work. Glad to see things are going reasonably well for you. I would say my leg strength is less than 50% the muscle is non-existant, still not able to do a single heel raise but I can walk, so I should not complain.

    Good look

  3. Tom, thank you for the update. it has been three years since my AT repair, and am still trying to build up the calf muscle. But the range of motion I know I have an elongated AT and am going through the eval process to see if a shortening surgery is required.

    For all of us pressing forward with our life and activities, I just want to offer my experience that you have to be extremely careful playing tennis. I have developed some bad habits, or other muscle usage to compensate the not-yet-fully-recovered AT, and it has bad impact on my knees and hips.

    I have stepped up the calf training, and hopefully it will at lease lessen the impact on other parts of the motion system.

  4. Hi Steve, Tom, and Annie,

    I am struggling with the decision of whether or not to have a second surgery for my elongated tendon. I am concerned if I don’t have the surgery, I will have other problems later in life in addition to just having a weak calf. Do any of you have any resources or advice?
    Thanks so much!

  5. Anju – Sorry to hear of your struggles. I know it’s a frustrating situation and not an easy decision to make. Unfortunately there are not a lot of resources available on this subject which makes it even more frustrating. It seems the elongated tendon situation is relatively rare, so there isn’t much literature on the subject. Achillesblog is probably one of the best resources, so I recommend doing a search on Achillesblog for “elongated”, “lengthened”, etc. and read what others have discussed. I assume you’ve read some of my blog, but if not, skim some of the posts and comments when you have a chance. I had the same concern as you regarding how a weak calf could affect you later in life. I got some mixed messages when I asked that to different medical professionals, but in my opinion, I don’t see how it can’t have some small effect on other parts of the body.

    I also recommend you talk to multiple ortho-surgeons if they are available in your area and get all your questions answered. One piece of advice I can offer is that you need to appreciate that there is no guarantee that a second surgery will get you back to full strength. My surgeon indicated that full strength was the goal and was possible, but that he would consider getting back to 80% a success. I would say I’m right around the 80% mark now, so a success, but not completely back to normal. I’m stronger than I was prior to the second surgery and I’m not limited in anything I want to do. But, I do still notice the strength difference. I just don’t have the same power in the affected side. I have spoken with a couple other people who had a second surgery. One seemed to be closer to full strength than me and the other was still struggling a bit. You just need to be cautious with your expectations when analyzing whether a second surgery is right for you.

    As I’ve indicated in my blog, even though I haven’t made it back to 100%, I have no regrets about the second surgery. I feel like I’ve done everything I can to make it back to full strength. If I hadn’t had a second surgery I would have always wondered if things could be different. Also, my life and job are flexible enough that a second surgery and recovery was not too much of a burden on others. That made my decision slightly easier.

    Good luck with your decision.

  6. Hi Tom,

    Thanks so much for getting back to me. I have read through your blog and the comments which has been super helpful. I really admire your strength to endure 2 surgeries. I am glad that you have gotten a good outcome even though you are at 80%. Very impressive that you are able to run marathons!

    I recently moved to the Bay Area so I have access to some of the best doctors. I have appointments at Standford and UCSF in the coming weeks. I have never gotten an ultrasound or MRI done on my Achilles. I definitely want to confirm my diagnosis before I make any decisions regarding treatment. I went to a primary care physician today. He said I have a ton of scar tissue. I’m guessing I couldn’t even have another surgery until a lot of that scar tissue goes away. I’m going to start up physical therapy again (I haven’t gone since May) and see if that helps build up my calf strength which is virtually non existent right now. Also, I’m curious about Gastron massage that you did. I’m wondering if that will help with my scar tissue. I will ask the surgeon about it.
    If I could get back to where I was in June (I was able to walk without a limp then), I think I would be happy. I guess I wouldn’t be able to run or jump but I am fine with that. I don’t think I could handle the second surgery. For mine, they said they would have to take tendon out of my foot but it sounds like you didn’t need to do that for your second surgery.
    Thanks again for your advice and help!

  7. I have a hypothesis. Healing long has something to do with the initial cast/boot angle. I think the mistake most commonly made is assuming everybody’s resting angle is the same, namely at 30 degree. I did a lot of research on the forum and surprised to find that there is only less than a handful of success stories.

    My success criteria is:
    1. The injured leg recovered to the same size as the uninjured leg, and
    2. The injured leg recovered to be able to perform one legged heel raise with the same height and weight as the uninjured leg.

    It’s truly amazing that with the number of recovery on this sites, there are so few, if any, success story.

    If you can’t do a single legged heel raise that matches your uninjured leg, you most likely healed long.

    I would really love to hear the rehab plan from any member who healed short.

  8. It is common for people to heal a little long with this injury. 5mm is considered a clinical failure. The intitial foot angle after surgery may be a factor but some have come out of surgery with a bit of tension on the tendon and have not healed long. Your success criteria is OK but others may differ in what they term success and there are hundreds here who would say they have had a successful recovery. I can one leg raise as good on my injured side as the un-injured and do them to fatigue equally as well. If I maintain calf specific exercises then my injured calf does not look any different in size but once I stop this it will shrink a little. I was up and down ladders a fair bit after 5 months while I was building but once the building stopped I have only been walking, hiking and some running. I live in the mountains so there is nowhere to walk without a hill so that is good for the leg. I would call my recovery a success as I can do everything I could before the injury just as well. It has been so long for me now that I would have to search my old hard drives to find my protocol but I was in a boot after a week and the angle was set wrong by the Physio. I changed my Physio and she increased the boot angle around the 4 week mark. I was already FWB by then. The boot came off around 7 weeks from memory and the angle change slightly each week. I weaned off it around the house first. Lots of balance exercises. Lots of eccentric loading early on. Walking was the best exercise and I had wedges in my shoes which came out over a couple of weeks. I struggled with dorsi-flexion but it came back fine and I can tell you I certainly did not heal long. Possibly a little short but I do not care to follow up on it. This could blow your hypothesis as the angle of my foot was much less than 30 degrees in the first 4 weeks. You mentioned Ryanb and I would say he is a good example to follow. Ryan came to the party a little after me and I would say his protocol would be a good example to follow.

  9. Hi xplora,

    Thanks for sharing your experience. I found a couple of common traits among the ones whom I considered successful:

    1. Slept with the boot off. (despite doc’s recommendation against it) (Did you sleep with the boot off?)
    2. Went biking before cast off/boot off.
    3. Went hard on rehab before week 6 post op and dial back because they heard it might elongate the tendon.
    4. Had and still have limited dorsiflexion. (I actually think this is a good thing)

    I also read that elongation happens around 6 to 8 weeks where the suture begin to dissolve and that’s when the tendon is most vulnerable to lengthening and re-rupture.

    I searched for “healed short” and didn’t find much result as compared to “healed long”. I read an research paper stating that tendon (non-ruptured) can’t really be stretched using static stretch. But the calf muscle can be stretched. It kinda dawn on me wondering why does’t the protocol let the tendon heal short (ish) and subsequently spend effort to stretch the calf muscle as the patient regain muscle volume.

    I think people who have trouble with calf size, strength and one legged heel raise height is because the tendon healed long and the calf muscle is already fully contracted, meaning that the calf muscle cannot shorten any more.

  10. Peter,

    The research indicates that earlier movement and PT leads to better outcomes for both operative and non-operative protocols.

    Any protocol that locks up the tendon, calf, and leg for prolonged periods of time (over six weeks in a cast, etc) is simply behind the times.

    Healing long can happen a number of ways, but is most commonly attributed to non-operative because the tendon is not physically re-connected and gaps can develop. Obviously, it can happen even if you go the surgical route, too, due to either the surgeon not re-approximating the angle correctly, or through unexpected stretching of the tendon during mishaps that happen in the first few weeks.

    My surgeon instructed that I was to wear the boot during sleep so the tendon did not retract/shorten, as this is its natural inclination during the earlier phases of healing.

    The jury is still out on my recovery (I’m only 6 months in), but others seem to think I’m doing good. My concerns about healing long are tempered by the fact that I’ve been able to tack on incremental gains so far with no major plateaus. I’m really starting to come to terms with the fact that it really is just a slow, annoying recovery no matter how hard I push. Additionally, I can get my injured side heel even with my uninjured side when standing on both, leading me to believe my inability to do so on SL lifts is simply the result of lack of calf strength.

    In reading others’ blogs here about healing long, it seems they all had/have major strength and size deficits up until the 5-6 month mark, where many are starting to engage in plyometrics and seeing significant gains in strength and size.

    The inability to fully SL raise is also often due to simple lack of strength.

  11. Petery - I did not sleep in the boot after 3 weeks as I needed to get some sleep. I was stationary biking fairly early but in the boot and more heel of the boot on the pedal. I did not go hard before 6 weeks. Probably went as hard as I could from 8 weeks but I did what I was told and within the bounds of my protocol. My dorsi-flexion seems to be the same on both but I did struggle early. Healing short can lead to problems in other areas. You can look up tendon lengthening and you may find something more. Some children have it when the AT is too short and they walk around on their toes. Having an enquiring mind is a good thing but it can lead to trouble if you do not fully understand. Run everything past your Physio or someone with good medical knowledge. It will make for interesting discussions while you are being treated and give you more to research when you get home. I think some of what you say has some merit but it is difficult to make any real analysis based on the anecdotal evidence of a few blogs. It may however give you a thread to chase. Good luck with it. I am sure you will do fine with your recovery.

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