Achilles Odyssey

The long road back

Wrong Diagnosis

On January 23rd I was playing soccer in one of our local league matches. I had just scored a goal,  we were up by two and things were going great. It was a couple of minutes before halftime.  I remember blocking a shot on goal with my ankles and getting a sense that something wasn’t right. I recovered a few seconds later, and got the ball on a break away.  I was running at full speed looking up field when I felt my  left leg snap  followed by an electric jolt and the sensation that my lower leg had detached. The immediate pain was intense and I crumpled to the ground.

The initial pain subsided quickly ,  but my team mates and the ref had me stay on the pitch covered in jackets until an ambulance showed up.  The paramedics cut me out of  my sock and shin guard  and did a preliminary examination.  The swelling wasn’t too bad and I wasn’t in much pain so I declined the offer for morphine. I asked them about the “snap” and the mentioned that sometimes you roll over your ankle and dislocate it. I was dubious.

I was taken to an ER in Manhattan  and rolled into triage.  Eventually a doctor came to see me and asked me if I was the soccer player with the twisted ankle. She was nice, but I got the sense that she wasn’t really taking this seriously.  She  had me wiggle my toes  and tilt my foot. I told her That I specifically felt some pain along the Achilles/calf. she poked me with her fingers in said region, said she didn’t feel anything and told me to wait for the X-rays.

Eventually,  I had my X-Rays taken,  then I waited for them to be read.  The first doctor I saw had gone home, so another doctor came to give me the good news that nothing was fractured, I had just sprained my ankle. I told her that I felt like some thing was up  with my tendon, and asked if she could examine it.

She had me roll over and poked around my calf inconclusively.  She claimed that there was no rupture as she felt no lump. She proceeded to wrap my ankle   in an ace bandage, gave me some crutches and stretches to do, and told me that I would be playing soccer again in two weeks.

This happened on a Saturday, so it was a couple of days  before I could make an appointment with an orthopedist.  The hospital gave me the card for one, but I decided to call a surgeon that came highly recommended by a friend and teammate. His earliest availability was a week later.

The week waiting for my orthopedic visit, was emotional to say the least. I still didn’t really know what was wrong with me. I researched sprained ankles, and surmised that I probably had a “grade 2″ sprain. A season ender, six weeks of no soccer or Muay Thai!   I hoped for the best, but deep inside I knew something was seriously off. I kept telling my girlfriend “something is up with my Achilles” I would stand on my bad leg, as advised by my ER doc and feel a sensation best described as rice crispies.

The much anticipated visit to the orthopedic surgeon arrived. His PA examined me, they took some more X-rays. Then the doctor came in and in thirty seconds flat said “you have ruptured  your Achilles”. He looked to his PA and said “let’s book him for surgery tomorrow.” I could tell by his demeanor that he wanted to operate immediately.  I asked about other options and recovery time and he delivered the final crushing blow.

Dazed, I returned home where I discovered the amazing Achilles Blog.

25 Responses to “Wrong Diagnosis”

  1. 2ndtimer Says:

    So many get misdiagnosed at the emerg. x-rays do not show anything.
    Hope you are on the right path to recovery now.

  2. marina Says:

    Welcome to the club! You’re not alone…wish you have a smooth healing.
    Oh, and Achilles was an Iliad hero :-P

  3. uligan Says:

    Thanks guys/gals! Yeah, the upside to getting misdiagnosed was that I ended up seeing an excellent surgeon of my choosing. I will post about my surgery in a future update.
    Yeah Marina, I couldn’t resist the irony- my name is Ulysses so go figure :) I look forward to swapping stories with everyone here.

  4. marina Says:

    That makes sense now :-)
    Keep us updated!

  5. placervillemadman Says:

    Sounds so familiar… I remember the doc squeezing my calf and he knew right away it was ruptured…he wanted to get me under the knife the next day. I had to have him delay surgery for a few days so I could plan to be away from work. Bummer news about your injury, on the ++++ side you will meet a lot of great folks on this site!!

  6. sfttourguide Says:

    Welcome to the club! Now is your chance to catch up on reading, DVD’s, yakking with friends and family, and feeling the helplessness of hopping on one foot. It is a real wake-up call about our dependence on other people, and how impatient we all are with our lives. I went through it in the summer of 2008 and still dread its recurrence, but I did get to read a lot, my favorite thing. I missed a whole summer of customers, couldn’t drive the tourbus.

    Hope you have something you like to do in a bed or chair, not involving walking! Even knitting might turn out to be more interesting than you think!

    DOn’t just play cardgames on the computer.

    Mary

  7. retiredfrombball Says:

    That is exactly why I went straight from the basketball court to the bar. No one thought I was really hurt because I could still walk and didn’t go to the emergency room but I knew I would wait for hours, get xrays and either be misdiagnosed or just told to see another doctor the next day.

    Good luck!

  8. normofthenorth Says:

    I don’t know if the ERs here in Toronto are any better than those in Manhattan, Uli, but virtually all the surgeons here would have tried to talk you out of the surgery, based largely on a new randomized study done about an hour’s drive from here, at Univ. of Western Ontario.

    Make sure you get a reasonably fast rehab protocol, and don’t be shy about asking all your health professionals when they last washed their hands! (Infections are the most common complication from ATR surgery.)

  9. uligan Says:

    This is why this site is so great!
    Placervillemadman- Did your surgeon express why he likes to operate right away? I have heard some surgeons like to wait a week or so for any swelling to go down.

    Sftourguide- I know exactly what you mean. Here’s to the unsung heros of ATR our friends families, significant others, and general well wishers! Fortunately, I am not short of hobbies, and my great GF bought us a PS3 so we can watch streaming movies and play FIFA 10! Other then that I have been working on my guitar skills. I might add don’t play chess on the computer!

    Retiredfrombball-Sounds like my kind of a game (league?)

    Normofthenorth- That is definitely food for thought. I must add that the surgeon I saw was not affiliated with the ER that I visited initially. He came highly recommended to me and I trusted his judgement on a proven track record. Honesty, I think I would have requested surgery with what I knew at the time. I am curious about the non surgical route. Looks like your blog is a good place to start.

  10. Christian Says:

    Hi there! Your story and mine are so similar brother! I opted for surgery the morning after the PA confirmed my injury! It’s been five weeks now and I’m finally in regular shoes. I still have a limp but I’m okay with that! I’m hoping to be playing soccer again this fall. Good luck to us!

  11. "Frouchie" or "Grouchie", or just "Chris" Says:

    Glad you found us!! This site has done so much to keep me positive and on track. It is nice to hear about everyones own story, but we all have a common goal…to recover.

    Keep us posted and take it slow. The recovery time is like competing against someone in a race, the only difference is in this race to goal is to take it slw and not get hurt any worst.

    “Slow and Staedy Wins THIS Race”.

    Good luck.

  12. retiredfrombball Says:

    the only thing my surgeon said was if you wait longer than 14 days, the tendon often pulls apart too far for a standard surgery and they have to take a tendon from another part of the ankle to make up the difference. More complicated surgery and longer recovery also.

    It is different everywhere but my surgeon said if you want to be active more than taking a walk with your wife, he strongly recommended surgery to to the re-rupture rate being much higher. I went in thinking no sugery and left 5 minutes later with the surgery scheduled.

  13. norcalsurf70 Says:

    Absolutely classic. If you replace soccer with badminton, I have the identical story. I was LOL through your piece (but I could feel your misery)…

    My ER doc was clueless. My Orthopod diagnosed me in 20 seconds without an MRI. He took the x-rays from the ER and tossed them without barely looking. I was in surgery for ATR repair 2 days later! At 5 weeks, I’m FWB and in PT. Life is improving and this site is one of the reasons why I’m feeling that much better about the recovery. Welcome and good luck!

  14. uligan Says:

    Christian and Dan, we are practically on the same timeline (give or take a week) The reassuring part of having such similar stories is that we realize that this is not such a freak accident, but a real part of the sports we love.I am impressed with your progress, I hope to be in a similar situation soon.

    retiredfrombball, that is pretty much what my surgeon said as well. Also, in the surgery they removed the damaged part of the tendon and shortened it.

    Chris, I am sure many of us will have your mantra in mind when we are tempted to rush things along.

  15. normofthenorth Says:

    I went in to a meeting with one of Canada’s fanciest sports-medicine SURGEONS, wanting the same kind of surgery I’d had 8 years earlier on the other side. Instead, he confirmed the diagnosis and told me he’d stopped doing the operation 4 months earlier, because of the latest randomized studies!

    Eight years ago, I was told that immobilization (”conservative” treatment) was for old folks and non-athletes, but if you cared about athletic performance, the surgery was a no-brainer. Since then, the best local sports-medicine surgeons have decided that AVOIDING? surgery is really the no-brainer! It’s easy to understand why the old wisdom survived so long, while all the non-surgical patients were being immobilized in rigid casts for MONTHS! (THAT’s no way to treat an athlete, or probably anybody.)

    In addition, I bumped into the daughter of some good friends who’s a new doctor. She said that two of her Med School classmates tore their tendons before finishing Med School. One’s a serious athlete, the other not so much. They both got non-surgical immobilization with quick rehab, and they’re both very happy with the results (as am I, so far!)

    BTW, I’d always heard that it was “The sooner, the better” with ATR surgery. BUT, my fancy sports-medicine surgeon told me that HE always preferred to wait about 2 weeks post-ATR before operating. He said that the time usually changed the tendon ends from “horses’ tails” to relatively neat and compact ends that he found easier to reattach. From the clotting and proto-repair mechanisms doing a bit of work. (Unless the tendon physically shrinks after the rupture, I don’t see why it would be hard for the surgeon to pull the two ends together, while your foot is plantar-flexed, in “equinus”.)

    Uli, if you’re curious about the non-op alternative, my first few blogs and their links are probably as good a place to start as any. (The fancy UWO randomized study has been presented at a fancy conference or two, but AFAIK it still hasn’t been formally published in a refereed journal.)

  16. mari Says:

    Welcome!

    You’ll find a wealth of info here.

  17. Sydw Says:

    I was also mis-diagnosed and sent on my way.

    After 10 days saw the physio, 2 minutes later he said go back to A&E

    The story so far:

    Jan 18th 2010, ATR playing squash

    Jan 29th ATR confirmed and put in full cast upto the thigh.(nightmare)
    (Non surgery route, thought I better not put conservative route)

    Feb 2nd Back to see Ortho - Decided to leave full cast on and come back in 2 weeks.
    not being able to do simple everyday tasks frustrating. (glad I found this site)

    Feb 16th back to Ortho - plaster caster taken off & a quick check to make sure that the tendon was starting to heal and on with a below knee cast.
    What a relief. The knee joints were a bit stiff, but after a few days they freed up and the knee felt okay.

    March 2nd Ortho appointment - Saw the main surgeon, told me off for not taking my fragmin, self injecting everyday. Decided to leave pot on for another 2 weeks, still in the same position.

    I asked a few questions and was told that I would probably have another 4 weeks in plaster
    (8 in total) I was bit taken aback with what he said next, I need to have 2 shoes adjusted so that the heel’s are increased by 5-8mm. and I would probably go straight into 2 shoes.

    This came as a bit of a shock, most if not all of the protocols I have read seem to go from
    plaster cast into some kind of boot then eventually shoes.

    Anybody else gone through a simalar transition, seem a bit scary to me - all too easy to re-rupture.

    What I have found is I have had to ask somebody to help with all but the simplest tasks,
    and what’s been enlightning is most people will oblige or even go out of there way to help.

    I’m one of those who would help anybody, but never ask for help myself - (stubborn old fart)

    so, thanks to all them & to this site.

    Sydw

  18. chocolata Says:

    Hi Sydw,
    It sounds familiar to me and I share your worries. My treatment protocol seems as follows.

    4 weeks & 3 days in below knee cast (equinus position) - I’m now 3 weeks & 1 day after ATR
    2 weeks in below knee cast (semi-equinus position)
    2 weeks in below knee cast (90 degrees)
    In two shoes

    The consultant I saw for about 3 weeks ago didn’t explain details of my treatment protocol to me (He was too busy..), and the cast technician gave me some information about what would happen next. I wanted to know more about my treatment protocol and, 2 weeks later, I called the clinic. The nurse gave me a little bit more information about it, but I was advised to talk to the secretary. So what I’ve written above is a kind of patchwork, but the secretary told me that they didn’t use a boot for ATR patients.

    I know a few people who went into 2 shoes right after a series of casts. One of them had a heal on his all casts and started PWB from week 3. He is in Week 13 now and is still making good recovery. The others have told me about their scary experience after they came across in 2 shoes, although they didn’t get re-rupture, except one. This guy didn’t do anything silly when he re-ruptured his AT in Week 12. He stumbled over a little gap on the street and much of his weight was put on the bad foot for a second. His AT couldn’t take the shock. He keeps telling me that it’s too dangerous to walk in 2 shoes right after the cast.

    I will start commuting by train in the rush hour from Week 10, when I am supposed to be in 2 shoes. I don’t think it’s safe and am going to ask for a boot on my next appointment with a consultant (10 March). Fingers crossed!

  19. normofthenorth Says:

    In the older days, like when I tore my first AT 8 yrs ago, boots were rare and casts were standard, at least here in Toronto (which is pretty modern and high-tech in medical terms). I went to a surgeon then who did a fair number of ATR repairs (though more hip and knee replacements), and he had never let a patient use a boot until I bullied him into it — and that was only after THREE casts!

    One standard method for smoothing the transition from cast to shoes is to use a “walking cast” — a strong fiberglass cast that can take FWB (especially if it’s wrapped in a “cast shoe” for traction and shock-absorption). Putting heel wedges in shoes is another way to smooth the transition.

    Boots are better in a bunch of ways — and I bet they’re even cheaper if all the costs are counted — but the professionals mostly do what they’re comfortable with, unless and until they change. The best use of a boot is to replace casts completely, and I doubt that it’s common now to prescribe a boot after multiple casts.

    My personal fave (after two ATRs and two different boots!) is a hinged — or more accurately “hinge-able” — boot like the Donjoy MC Walker, which can immobilize the ankle completely at first, then allow a protected ROM that allows increasingly natural flexion with FWB.

    Even under ideal circumstances, the transition to 2 shoes brings heightened risk of re-rupture. The less strong and stable the foot is when that’s done, the higher the risk and the longer the period of risk. A foot that’s been (a) NWB and (b) in extreme equinus and (c) casted so the other foot functions and muscles (stability, proprioception, etc.) are also atrophied, is likely to be extremely incompetent at handling 2 shoes, at first. To me, it seems like learning to bicycle by starting at the top of a big hill. If you have time to stay home and “silly walk” around for several days, it’s probably do-able.

    (My own pretty good protocol suggested a return to “crutches as necessary” when weaning off a fixed AirCast boot at 8 weeks. That sounded dumb and unpleasant to me, so I used the hinged boot I already owned as a transition, instead.)

    Whether the risk of putting a weak foot into 2 shoes is worth it or not depends on who you ask — e.g. doug53 started with 2 shoes (and barefoot) extremely soon after surgery (straight from a splint and wrap), and had an excellent outcome. He’s a clever and sensible fellow, though, and he may have also been lucky. And he’s definitely only a single data point, like each of the rest of us! Maybe a randomized study using that approach would show 10% re-rupture rate instead of ~2%. Worth it? Hmmm.

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