Conservative Achilles Treatment on the NHS

So after a slightly unnerving flurry of activity I went from one crutch and the boot to two shoes (with gel heel inserts) in 4 days. This also meant that I could get back into the office in London after 83 days “working from home”. The short walk from home to the station takes twice as long, and once in town I get public transport. Being the slowest pedestrian in London rush hour is no joke, and even a “prop” crutch in the first few days it made little apparent difference to anyone else’s awareness of the fact I was less mobile. Feeling miserable about it, I saw a wheelchair user own and a mono-ped amputee getting up the escalator and decided that I should just get on with it. I now get the bus from the station in the morning and walk the full mile back after work. Not easy along Camden’s uneven paving slabs and tree root hummocked tarmac.

My second physio appointment brought new exercises: a 30 second calf stretch, and balancing on the bad leg, which is quite a challenge. I was also offered contrast bathing (2 minutes in hot water then two in cold ending on cold) to reduce swelling in the ankle, but didn’t try this as it can be quite uncomfortable apparently.

After two weeks of these exercises, the results of which seemed to please the physio, the next set have been issued. A double heel drop for 30 seconds twice a day, and tehn the same with a short hold going up onto toes. Also have to heel / toe along a straight line, which can be embarrassing  if being watched… arms wheeling etc.

I have “turned” the ankle a couple of times and had a small stumble, with only a few twinges in the tendon though this could be the cold and damp. The only real discomfort has been from swelling around the ankle and some  joint pain caused by lack of use. Tendon is thick, and I feel more confident on it by the day. Stairs up, no problem, but going down is still two feet on each step and cling to the handrail… no flexibility to allow usual descent yet.

Weeks 9 10 11 

One of the strange things with this injury is that as you move through the stages of recovery the first days can feel like a step back. Having got to the Aircast boot it took a few days to get to grips with it. http://www.aircast.com/index.asp/fuseaction/products.detail/cat/2/id/75

I felt confident enough in it to go for a long weekend camping with friends and family, which at least meant that the entire summer wasn’t just spent getting over this thing. We even had a day of hot sunshine at last… I picked a good summer to sit out playing cricket.

When I had to walk my daughter the half mile to school I decided to do it on crutches rather than set off an hour early. Maybe I had taken the rest and elevation to extremes, but this was, pathetically, the furthest I had been on crutches and I was left with blistered palms. As a result I couldn’t use crutches so was forced to go FWB in the boot… which felt fine.

Having chased my physio request form around the various hospital departments for two weeks I had my first physio appointment and only three days before the next specialist appointment to assess how well physio had been going! It seems that not everyone gets physio on the NHS, so I can count myself lucky. After the usual questions and form filling I was given a yellow Theraband and ankle rotation exercise. The physiotherapist suggested that I had been a bit hasty walking going FWB in the boot and should stay on crutches until I had seen the doctor, but she did say that with his approval I could start more aggressive exercises and join the Lower Limb class.

A few days later and 11 weeks post-rupture, I duly crutched in to see the doctor - the same one who had kept me in my second plaster for an extra three weeks, and the first to see my twice. He then politely told me off and said that I should have been walking on the boot for the last fortnight. With a less than re-assuring “It doesn’t matter what we do now, there is always a chance you will re-rupture, see you in six weeks”, he packed me out of the door with a wave and gel wedges for my shoes.

Went home in a state of shock and decided to spend some extra days FWB in the boot to make up for the lack of practice, and  I had an important meeting in a few days that I didn’t want to jeopardise.. After a few days in the boot walking was becoming quite painful with bruised feeling in the ankle joint and bones popping and clicking, presumably as the foot spreads back.

Eventually with the important meeting out of the way I tried two shoes for the first time. Two laps of the living room with a crutch and then I went for it… no problem!

Three days in and it feels great to be rid of the boot and crutches, but paranoia and the snails pace hobble are frustrating. I still have a tender bruised feeling in the front of the ankle joint when pushing off on walking, which I guess will reduce with use and physio. The tendon and calf muscle feel tight and I have not tried to stretch these yet.

Tomorrow I will venture outside on shoes for the first time to watch number two son play football… I may well take a crutch for extra support!

The Family came back tanned and healthy looking despite what was described as a wet and windy fortnight in Normandy. Probably just as well I didn’t make the trip as work has been frantic and really filled the two weeks of self sufficiency. With my chauffeur back I was ferried over to a new business meeting half an hour away where the injury made for an interesting ice breaker and the hosts kindly made allowances with a groundfloor meeting room.

I went down to the cricket club to watch my eldest son play a match. I got roped into scoring but couldn’t get comfortable on the bench and there was no room for a prop chair in the scorebox. Perhaps mercifully the game was abandoned at the tea interval due to monsoon conditions. The foot was down for the longest spell in 6 weeks, and the leg swelled noticeably pressing against the normally flappy welly top of the plaster. Purple toes returned with a vengeance, but alleviated when stuck back in the air.

After a week back, the intrepid campers were off again, this time for the wonderful

Green Man Festival in the Brecon Beacons. This was tough as it has been my highlight of previous years, and I bought tickets back in February. I had been in touch with the organisers who said that I could get a pitch in the disabled camping area with proof of disability from the Doctor. However we  couldn’t have our 8 man tent and couldn’t be with our friends. With this in mind and a large dollop of weather forecast induced common sense I Ebay’d my ticket at the 11th hour on Ebay. The last two days of the festival were solid rain and the entire site, including much of the main marquee, was turned into a quagmire. How those who my wife saw crutching around on Friday got around I can only guess… they may well have been trapped in their tents. One visitor is after some compensation as he has only one leg and had done himself a mischief trawling around the site after being assured by organisers that the site was accessible. Very poor. A great festival, but seems to have let itself down. Content that I made the right decision to stay at home, I tucked into my Ocado supplied Pieminister “Chicken of Tarragon”pie…the culinary delight first sampled at Green Man 2006.

On the eve of my 8 week anniversary, I made my third visit to the fracture clinic. Plaster off, bliss, and then wet-wiped a moulting Labrador’s worth of leg hair off and awaited the experts. Fourth different consultant arrived and was very enthusiastic about the results he has seen with conservative treatment. Seemed to be happy with what he saw and squeezed, and introduced The Boot. He recommended that I always wear it when upright and can try walking on it without crutches once I feel more confident. When resting , boot off and elevate, no icing (no pint at this stage), and the D&P flexing. Here’s the nurse, see you in three weeks.

Now one thing the NHS have certainly got the knack of is their accessory co-ordination, with every shade of grey applied to crutch and boot, whether metal, plastic or fabric. My poor quip “Have you got in blue in a size 10 lace up” was  ignored with the brusque efficiency of the overstressed and underpaid.

Feels really good to sleep without a cast and see the lower limb again, though the shrunken proportions are not enhanced by the huge lovebite on top of the foot the equates to the gap between the neoprene flaps of the boot.

I think for my last 3 weeks in plaster I was not quite at 90 degrees, so wearing the boot has been uncomfortable on the tendon, as it stretches out the last few degrees to meet the insole. This discomfort means I am reluctant to try walking on the boot. Hopefully that will ease in a few days and I will get more confident.

My PT “application” is in at a more local clinic. My wife had to wait three months for her post knee-op PT. Hopefully I won’t have that long a wait!

Went to a new business meeting today, and wore jeans for the first time in 6 weeks. Strange then that I should realise today how much the thigh muscle has wasted away. I have been lazy doing leg raise exercises with my good leg, but assumed that the bad leg’s thigh was getting plenty of action holding plaster cast off the floor etc. Clearly not!

Any suggested exercises for a plaster cast leg that will strengthen the thigh in advance of PT starting in 2 weeks or so?

Having spent three weeks worrying about how I was going to cope when my helpers went off camping to France, it has been surprisingly easy. The two weeks have flown by due to being busy with work which has eaten up the daylight hours. Self catering has been a happy combination of Ocado home delivered ready meals and making sure I eat some fruit and nuts. It has been easier being able to troll around the house at my own pace, feeling in control rather than in the way!

Hardest to cope with has been the very un-English hot an humid days when a trip up the stairs leaves me exhausted and dripping. Having a great big sponge strapped to my leg doesn’t help… and after 4 weeks in the same pot it can’t have been very pleasant in there. Pity the nurse when they took it off!

When I last saw the specialist I mentioned that I had a pain in my calf in my good leg which he thought was just the muscle adjusting to the extra work it was doing. What felt like a twinge became a constant pain, very tender to touch, uncomfortable when the foot was down and the foot was changing colour as if blood was pooling. After a bit of internet searching (not always a good thing) I managed to convince myself that I had a Deep Vein Thrombosis. Being over 40, over weight and underactive with an injured limb, I could have been a prime candidate. A call to NHS Direct eventually looked as if it would result in a blood test and a visit to my GP, but eventually they talked me down and suggested it was just a grumbling muscle. Peace of mind and within two days the pain disappeared.

The fifth week in plaster started with the strange feeling that my foot and calf were “talking to each other again”, something of a relief when you haven’t been opened up by a surgeon with a staple gun who can reassure you that the ends are connected.

After 4 weeks is this plaster it was a relief to be unwrapped at the fracture clinic. I had a good chance to look at my withered lower limb before the doctor came in, the third to offer his opinion. He soon had me with one knee resting on the couch and the good leg on the floor. He asked me to push up against his hand and then push down like pressing the accelerator in a car. It all felt very weak, but his prognosis was another three weeks in plaster as close to right angles as they could comfortably get me…. and then into a boot. So that will be 8 weeks conservative treatment in two positions of plaster before FWB in a boot. Unusual?

I asked the plaster nurse why my foot had not been plastered in full equinus, and she said that plastering where the foot hangs is best position as it is much easier for the patient. She only sees “ballet point” equinus on ATR’d holidaymakers returning from Europe. My last plaster had a rigid strip down the shin bone to keep the toes down, but this one has the reinforcement down the calf and down the heel, keeping foot up near right angle… effectively a NWB boot.

Still little pain, just the discomfort of the blood pooling in my foot when upright, but this is always balanced by the euphoria of getting the foot up in the air again!

As the clinic closes at 1230 I knew that time with the consultant would be limited… but after a 90 minute wait I was hoping for more than 3 minutes! Naturally it was not the same doctor I had seen before when deciding on the conservative treatment. He frowned as he looked at the plastered foot and said the immortal words “This is not equinus”… and proceeded to demonstrate with my other foot what position I should have been plastered in. He said that it was not safe to replace this plaster and I agreed that safe is a good thing.  I asked him if  the ankle being set incorrectly meant that the loose ends were less likely to join up, which he dismissed with a “healing is inevitable”. Interesting! So home I hop in this 2 week old plaster to return in a fortnight, when I either continue towards the right angle, or find that there has been no healing at all.

So the next two weeks will be spent alone (the wife and kids are off to France camping) wondering if Doctor the Second is right. I am concerned that this missed opportunity to see under the plaster would be have revealed that the rupture was too wide to heal conservatively and that an operation was necessary. We shall see. Eventually.

Six days after rupture I have my appointment to see the specialist at the local Fracture Clinic. A nice young man (and a cricketer), who allayed my fears of a double rupture by revealing that in his career – all of five years – he has never known anyone manage to rupture a second Achilles whilst in plaster after ATR. He laid out the options for treatment and I was really struggling to decide. He suggested that as he had other people to see that I could go out and discuss in the waiting room with my wife… not the most private place! This was the choice presented to me:

1. Operation: at another hospital “sometime this weekend” subject to other priorities. No guarantee on the surgeon or surgical method, my specialist did percutaneous op, but wouldn’t be on duty for a few weeks. A “relatively common” chance of complications in wound healing due to poor blood supply to injured area under plaster, which could need skin grafts. Plus usual hospital risks of MRSA etc. Possibly two fewer weeks in plaster cast. Only 4 in 100 re-rupture. Best chance of resuming sport.

1. Conservative: A new fibreglass plaster today (a good thing… this one weighs a ton) in full equinus position, then 4 more at fortnightly intervals. 8 re-ruptures in 100, best option for sedentary workers, the old and non-sporty types.

 I had been psyching myself up to surgery most of the week as this would be my first general anaesthetic. I had “The Snip” under a local anaesthetic a few years back, an interesting exercise in mind over matter… and a novel use for a bag of frozen peas. The specialist said that he would always recommend surgery, but then I guess when it is your livelihood maybe you would!! If you see a dentist complaining of a sore tooth he doesn’t suggest liquidised food and a straw does he?

I had already had a really tough week with the heavy plaster and its associated aches and pains and that presumably must have had some healing benefit… was that – plus a couple more days of the same -  going to count for nothing just to be cut open, cleaned up and stitched back? That tipped the balance really, why wait longer and then have to start from scratch? I figured that as I was not going to play cricket again this summer that I was in no hurry. I recently qualified as a kid’s coach, and could focus on getting back to that in January as a goal, then that would help me cope with not playing again should things not work out long term. I can work from home and its flexible so no worry if I don’t pitch up there for a month or two.

I backed myself to heal “naturally”, so it was back to the plaster room and goodbye John Merrick pot, hello slinky new lightweight number… see you in two weeks.

It is much easier getting up and down stairs, however I am still getting a lot of discomfort and purple toe action whenever I get upright. This is instantly relieved when I get the foot up again, but still makes for hurried trips to the loo. I haven’t been able to work out any method of even getting into the bath / shower safely (for me or the bath structure!) so some fairly inelegant sink work is required. Discovered the memory jogging smell of baby wet wipes. Hopefully this blood pooling in the foot will ease in the ensuing 8-12 weeks in plaster.

Sometimes when the foot is up and rested like it is now I can feel a steady tugging between tendon and calf… maybe fanciful but I like to think that is some healing going on. Sleep has been ok though I never used to sleep on my back and certainly not with my foot propped up. When I wake in the morning I treat myself to a snooze on my left side with the bad ankle on its side, with a cushion supporting the knee. Bliss.

I’ve been out of the house twice. Got out to see the kids Summer Concert which was a welcome taste of reality, even getting a front row seat with footrest and cushion! Also had what we laughably call band practice – me and three other dads strumming away attempting a collection of well known covers for a campfire sing along with the wives on a planned camping trip in late August. I started learning the ukulele about 3 months ago – having never played any music before. Plenty of time to practice now!

So having been lucky enough to see my team win the cricket match, I hop off with my well iced and floppy ankle to face the inevitable analysis at casualty. My wife dropped the kids – mid Dr Who - with friends and drove me round to the local A&E. Ironically enough, I suppose, this is the same department that I went on a protest march to try and keep open!

Casualty was fairly quiet for a Saturday afternoon, too early for the pub fallout, so I was seen fairly quickly which was a relief as the ankle was getting uncomfortable. Clearly there was something serious happening elsewhere as there was a bit of “I’ll be back in a minute” going on, but then ATR is not a high priority! Very jolly doctor, who confirmed my self diagnosis after she had me kneeling on her chair. First offer of surgery or conservative treatment with chances of recovery for each, she also made it clear that any op that I did have couldn’t be done here, but at a hospital half an hour away…and even then not until after the weekend. Decision was to put me in plaster and when I see the fracture specialist “in a few days” I could decide about treatment method.

Trolleyed off to plaster room and on goes the old fashioned plaster of Paris pot which then has a two inch strip removed from the front to allow for swelling. Nice. This all then wrapped up in crepe bandages.  A new set of NHS issue grey crutches and there is the door and the ride home with a packet of Co-Dydramol for the pain. First available appointment with the specialist is Friday morning! A six day wait. Harumph.

Back at home the first challenge is the 45 degree slope up to the five steps by the front door! Then the joys of townhouse living… stairs to everywhere. Backwards on hands and Nature’s padding with a bit of lever from the good leg and I’m inside and up to bed at 10.30.

Heaving me and the pot around is hard, and various “niggles” pop up across the week, in groin, back, thighs and, most worryingly, in the left Achilles and ankle where I had the tendinitis the weeks before the right one ruptured. How are you supposed to cope with a double rupture? After a couple of days I stop taking the pain killers as they have an unpleasant (if useful!) side effect on digestive process, plus are apparently addictive…  though they didn’t seem to do a great deal anyway. Phoned NHS Direct and they suggested I switch to ibuprofen and paracetemol in alternate doses. Try this for a day or two, but there is little pain, other than when the foot is below horizontal.

Being waited on hand and ankle by my wife – and even the kids - which really helps, but they are all off to France soon for a fortnight’s camping. The proverbial elephant in the room!

Foot up in bed all week really and with one of the chaps at work on holiday, a fair amount of work from home. Thank goodness for wireless broadband and remote access to the work server. Work phone is forwarded to my mobile, so as far as clients are concerned I am fully operational… except I can’t come and see them!

Hi… as someone who has worked in advertising for sometime, maybe it is a bit odd that this is my first attempt at blogging. I mean, what is all this free exchange of thinking about? It was always something I had scoffed at.

So why am I writing this? When looking for more info on achilles ruptures I was surprised to see such a busy support community. Then came the realisation that the vast majority of bloggers appeared to be “Johnny F” and recovering from surgery. Whilst I can understand the lifechanging evangelical “lets do this together” slant, it is frustrating if you want to know what the experience is like for those not spending their own money and doing it through public health.

Maybe this blog will be of help to someone else. Or maybe it will just help keep me a bit more sane… after all without the excitement of surgery, air boots,stitch removal et al, a couple of months in plaster has few milestones!