Week 3 - A follow-up appointment - Bad news

On the weekend, my experience at the boot fitting was still bothering me - it just didn’t seem like everything was right.

I decided to research how much pain people experience when their angle was adjusted, and whether anyone felt any “tearing” sensation.

I did find one reference to adherence of the tendon to the skin via scar tissue - but that was a report from much later in the process.

Also, there didn’t seem to be many reports of significant pain when getting put into the boot.

I started getting worried enough, that I decided to call the on-call doctor (Unfortunately it was President’s day weekend by now, and there was no way to contact my regular doctor).

After hearing my description, the on-call resident predictably asked “So what’s changed since Wednesday?” and I had to say nothing, other than I started getting worried.

He basically told me there wasn’t much he could do for me, and that the best path was to contact my doctor’s office next week to see if they could see me. He did confirm that what I described didn’t seem normal, and that he would be concerned.

As an aside: One of the things that’s been the hardest for me to take about this experience is the long periods of uncertainty - I like knowing what’s going on, and can usually cope well if I have an idea what to expect. The uncertainty is just stressful to me, and it seems there’s been many periods where I had an idea that something was wrong, but no way to get confirmation (like after my initial misdiagnosis, for example).

In any case, I settled in to wait - my doctor’s office scheduled an appointment for me a week after my previous appointment, on Wednesday.

Of course, as the things go, the doctor was running an hour and a half late that day.

After a long wait I was led into an exam room.

The first person to see me was a resident (he didn’t introduce himself that way, but I figured he was likely to be one, and later confirmed this via some cyber-stalking).

I described the whole experience to him, and he listened carefully.

He then asked me to lie on my stomach on the exam table and to bend both legs at the knees.

He squeezed both my calves and then palpated (probed) my bad leg extensively around the tendon.

He left without comment and said the Doctor would be in to see me in a minute.

Shortly after this, he and my main Doctor returned and she repeated the process.

They briefly discussed whether they could do an ultrasound on the spot (It was 4:45 pm, by now), but ended up deciding to schedule an MRI. They told me I’d probably have to wait until the next day, because it was too late to get in on the same day. The doctor said she’d call me when she had a chance to view the results.

I asked how much pain people normally experience getting put in the boot - and she said emphatically, “None.”

I ended up getting scheduled for a mid-day MRI the next day. This was my first MRI, and it was quite an interesting experience. I highly recommend bringing your own earplugs - I brought mine but stupidly didn’t put them in before the procedure. They did provide a sound-reducing headset, but I would have liked some additional sound deadening. The hardest part of the process was trying to stay still during the scans. The longest scan was around 8 minutes, but most were between 4-6 minutes for a total of around 45-50 minutes of scanning.

I asked for a copy of the MRI on the way out, and they were able to give me a CD within 5 minutes.

I took the CD home, and as a pleasant surprise, saw that the images came with some viewing software that I could run.

Here’s what I saw (this is a slice toward the back of my leg, viewed from the front of the leg - the red circle is on the right side of my Achilles area):



After another 24 hours of impatient waiting, my Doctor called me.

The irony of her first words didn’t strike me until after the call: “Are you sitting down?”

She told me that it was a rerupture - she said she couldn’t understand how/why this would happen. They had used the strongest sutures you could use, and nothing like this had happened before. She had a few reruptures, but they were caused by accidents (one individual tripped over a toy once out of the boot, and caught himself with his bad leg).

I told her I’d seen the MRI and it looked to me that the tear was actually slightly above the repair. She mentioned that there’s often a lot of scar tissue post-surgery and that it can be hard to figure out exactly what’s where.

In any case, she said they’d prioritize me for surgery next Thursday (this was yesterday afternoon as I’m writing this, so the surgery will be on 2/28) and that her surgical assistant would call to arrange the details. After that we said our quick good-byes and hung up the phone.

Two minutes later, she called back. She said she had taken another look at the MRI and that I was right - the tear does appear to be above the site of the original surgery and she *really* couldn’t explain what had happened. She said they’d be able to tell more when they opened me up, but this was very unusual. I asked if she would still recommend surgery, and she said yes, with the size of the gap that she saw.

In any case, I’m finally caught up with my blog - the rest will be posted near real-time.

It’s a bit of a bummer - I’ve now lost four weeks and bought myself a possibly more complicated recovery. I don’t regret choosing surgery as my path, and would almost certainly do so again, but there’s no doubt that this incident would probably not have happened had I opted for non-surgical treatment.

It’s also a start reminder that regardless what the statistics are, ultimately as an individual your chances for a complication are either 100% or 0% - so be it.

15 Responses to “Week 3 - A follow-up appointment - Bad news”

  1. Sorry to hear the news. Your case doesn’t sound like it’s an usual occurrence, but keep your head up. I would rather something like this happen on Week 3 than Week 12 which is when you hear of most of these happening (when people are FWB and moving into 2-shoes). Hopefully, the surgeon will get in there and create a stronger repair, which in the end will heal better. Good luck.

  2. Ya, good luck, Ulrich, sorry about the bummer. And continue being your own “patient advocate”, and a continually better informed and “pushier” advocate, too.

    It does seem superficially unlikely that a recently repaired AT, overstressed, would tear in a brand-new spot removed from the repair. OTOH, the 3 totally inconsistent UltraSound exams of my more recent ATR (done at 1-week intervals to guide injections of PRP) included one that seemed to show multiple partial ATRs. While most overstressed ATs will rupture in one place, the whole tendon is usually loaded to the breaking point at the time of the rupture, so it’s not obviously nuts to expect that some parts that didn’t separate were weakened, too.

    I think one or two of this site’s “re-rupture” patients actually experienced a second rupture on the same AT, relatively early post-op or post-non-op.

    Did you notice at the painful and eventful boot-fitting that the boot’s ankle-angle was significantly less plantar-flexed than you’d had for 13 days in the cast/splint? Those angles should be virtually identical, IMHO. The reason your footwear is changing at about 2 weeks post-op is only because your incision is expected to seep and ooze for the first week or so, so an absorbent and disposible plaster cast (often surrounding some absorbent and disposible gauze) is handier than a boot you’re going to be wearing until ~8 weeks post-op.

    Several others here, during “my time”, have experienced difficulty accommodating to ankle-angle changes during rehab, though I can’t recall another rerupture from it.

    And yes, it’s true, we are individuals, not statistics, and certainly not medians or means. And the probability function of our own reruptures never ends up at the 3% or 5% or 15% of the various studies, but always “collapses” to 0 or 100%. In a very different context, there’s a brilliant essay online by Stephen Jay Gould you might enjoy, called “The Median is Not the Message.”

  3. Ulrich, I’m so sorry to hear your news.

    Can I ask what may be a silly question? I’m just over a week in an aircast after two weeks in plaster post op. Could you walk on your boot after if was fitted?

    I spend most of my time in fear that I am about to or have re-ruptured. I’m super careful on my crutches but have started to experience calf pain and soreness around the wound in the past few days and I worry that I have overdone it and had a mini-rupture.

    I am PWB and can still put weight on and walk on my foot with crutches.

    Thank you

  4. Norm - As always, thanks for your words of wisdom. To answer your questions: Yes, I believe the angle of the cast was quite relaxed - I had a splint made for sleeping before they placed me in a boot, and that was already a bit painful. The boot seemed like it was really tight.
    I have a picture of the cast after it was cut - I’ll upload that so you can see. (FWIW, you’re absolutely right about the cast and the absorbent material - you’ll see in the picture that the cast was packed with cotton wool, which fortunately, in my case was overkill - I had very little seepage - none that made it outside the dressing over the wound.)

    In terms of the modality of the (re)-injury: I was thinking that in general if you stress a system to a breaking point, the weakest part lets go. That should kind of act like an electrical fuse does to protect the rest of the components. The other thought is that the rebound at the point of “snapping” may introduce all kinds of weird stresses that might be able to cause damage. My research seems to indicate that several people have had calf strains at the same time as an Achilles rupture, so my “fuse” theory might not be correct.

    I’ll see if my surgeon has any possible explanations, though I’m unfortunately now in a category of unusual cases that will probably make it much more difficult to find good information.

  5. Joya - My surgeon is fairly conservative about the recovery protocol. I’m supposed to be completely non weight bearing for the first six weeks (they’ll be adjusting the angle, but I’m not supposed to put any weight on the leg until I’m at 90 degrees). Having said that, since the reinjury, I’ve experimented putting light weight on my bad leg, and I can do so with no discomfort.

    From what I’ve read however, (and I’m sure Norm will corroborate this), it is quite usual for a more aggressive protocol to have you partially weight bearing as soon as two weeks.

    While in the boot, your foot is so well supported that the tendon is very well protected.

    Your instructions sound very consistent with what I’ve read elsewhere.

    My advice is to follow your doctor’s protocol. Be willing to ask for the reasoning behind the protocol, and if you’d like to change something about it, discuss it with your doctor, but ultimately you should go with what the doctor says. (If you find that the doctor is not giving you advice you like, then find another doctor rather than just modifying your protocol yourself).

  6. Thank you, that is really helpful.

    I hope you have a better recovery this time around

    Take care

  7. Ulrich, in a system that’s engineered with an intentional “weak link” — like an electrical system’s fuse/breaker or an outboard motor’s shear pin etc. — that link is significantly weaker than the SECOND-weakest part of the system. The weak link is also, by design, cheap and quick and easy to replace.

    Alas (or maybe not), our ATs are not designed that way. Instead (like every tendon in our bodies), they’re designed to be much stronger than the muscles (calf) that pull on them. Unfortunately, that system occasionally fails, which is why we’re all here. And fixing it is slow and frustrating, which is why we all have so many questions, details, and answers!

    In a system like an AT that’s designed not to fail by over-stress but does anyway, it’s anybody’s guess whether the “second-weakest link” is strong enough to survive the rupture without damage, or not.

    A related question that most of us have puzzled over, is just how strong our ATs were a day, an hour, or a second BEFORE our ATRs. A minority of ATR patients have AT problems before the ATR, and many of those folks blame themselves for continuing to run or jump or whatever. For the rest of us, the ATR came “out of the blue”, but that obviously doesn’t mean that our AT was perfect just before it tore. Given that uncertainty about the “weakest link”, why should we have any more certainty about your second-weakest link? Maybe it looked fine to your surgeon but was really very close to failure? Maybe it got (subtly?) damaged in the op, as the surrounding paratenon was stripped away from the tendon?

    Like so many things in medicine, it’s easier to find a treatment (or two) with a good chance of success, than to answer all the How, What, & Why questions. And that’s better than the other way around!

    @Joya: You should be able to examine your foot to see what the incision/scar looks like, etc. And you may also be able to adjust your AirCast’s straps and padding, etc., to make your leg more comfortable. Some incisions get inflamed or infected or don’t heal well, etc., etc. If yours looks OK but still hurts, I’d do two things: (1) take it easier with the PWB and (2) phone your Doc and maybe get an exam sooner than planned.

  8. @Joya & @UlrichW: As RyanB outlined on a GRAPH somewhere on his blog, even comparably aggressive protocols can be quite different in their timing of specific milestones, including the move to PWB and FWB. UWO goes to PWB at 2 weeks and FWB at 4 weeks, which is pretty quick, but waits for 6 weeks to change the ankle (plantar-flex) angle, which is on the slow side. Ryan’s Doc’s approach went the other way around. I doubt that his approach is as well tested and proven as UWO, but it may be just as good or better, and seems to have worked fine for Ryan.

  9. Here’s the graph Norm is referring to:

    achillesblog.com/ryanb/files/2011/12/bootpath.jpg

    I deleted the post/question it was created for when cleaning up my blog a while back. My question was basically: which path should we take.

    My doc didn’t give me much guidance- I was just told to wean off the boot as I was able. The path I took was just based on recovery from other injuries- I’ve always worked on range of motion first, strength second. So, I worked to get all the way flat in the boot before trying to increase the load to FWB. It was only after the fact that I realized that - for this injury - that’s kind of an unusual approach.

  10. In case it’s not obvious: I followed the “green path”, while a lot of protocols like UWO seem closer to the “red path”.

  11. @ryanb & @normofthenorth, thank you this is really helpful.

    I am just panicking as I’ve had a few days of pain and discomfort and put this down to a re-rupture (even though I haven’t don’t anything that would cause it). My leg has settled down again now and I can PWB with no pain.

    I’m not concerned with my treatment so far, I just don’t like the unknown!

    Thank you again and @ulrichw sorry for hi-jacking your comment feed!

  12. Joy- if putting pressure on it hurts, it’s probably not re-ruptured. A re-ruptured (severed) Achilles is incapable of carrying load - or transferring stress/force into the joint.

    For the ~36hours between my injury and surgery, the Achilles area was remarkably pain free. I could hobble around on it without causing too much discomfort. It was just totally unstable and weak. Mind you, the recoiled calf muscle was VERY sore… but the Achilles itself: just a non-responsive, lifeless puddle of mush. There was nothing pulling on it; nothing to pull against.

  13. I can walk with crutches pain free. My calf has ached a little but I put this down to cramps.

    It doesn’t feel weak or unstable when I am crutching around.

    Most of my recovery post op has been pain free, so I am lucky in that sense.

  14. @ulrichw, @normofthenorth and @ryanb, just wanted to let you know I say my surgeon today. He is really pleased with my recovery. No tears or re-ruptures.

    Thank you so much for your advice earlier in the week. I was rather ‘on the ledge’ about things and worried, so thank you.

    @ulrichw, I hope everything is going well with your recovery

    Joy

  15. Joy - really glad that everything is going well for you; It’s easy to get worried about how things are progressing, especially because every case tends to be a little different.

    One thing that I took away from reading many of the blogs on this site, is that pretty much everyone eventually recovers - so no matter if there are a few setbacks, we’ll still make it there eventually.

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