Wayne’s Achilles Blog

My one year anniversary is almost here. I would’ve never thought that I’d be back to running any races longer than a 10K this soon. Today I finished the George Washington Parkway Classic 10 Miler very close to my time when I ran it two years ago! Up to this point, I’ve only been running in 5Ks and a couple of 4 milers. And today, I had the opportunity to hop off the bus for the 5K race. But instead, I felt the need to remain on the bus and head over to the 10 mile start line for this point-to-point race (Mount Vernon to Old Town Alexadria). And I’m very glad that I did!

It’s been awhile since my last post.  I met a major milestone today so I thought I’d post something on my blog page. Today I ran 5K on a treadmill without any walk breaks for the very first time.  And so far I’m still in one piece! No aches, no pain!

This past weekend was the Marine Corps Marathon. My girlfriend and I went to the Mile 23 marker and cheered on the runners (especially the slower folks) and supported them by handing out candy, cookies, bananas, and pretzels. Watching all of those runners really got me thinking of how much I missed running. So I made it point to go to the gym tonight and seriously begin on my recovery to race again. I think it may still be awhile before I pursue a marathon. But I definitely want to get back into running 10K’s and perhaps set a goal on running a 10 miler and/or a half marathon. We shall see!

My ATR recovery is going quite well.  I’m now at a point in my recovery where I visit my physical therapist once a month.  In my last blog I mentioned that my physical therapist started me on a Return to Running Program that is based on a program designed by Steven L. Cole from the College of William and Mary.  The complete program is explained at http://www.step-rite.info./files/Return_to_Running_Program3.htm

I’m currently in Phase 2 of this four phase program.  My therapist has me on a regimen consisting of a three day rotation of exercises:

1- Weight training for the calves (strengthening)

2- Double and single leg heel raises (flexibility/range of motion)

3- Return to Running Program

Here’s a summary of the Return to Running Program.

Phase 1:  Walking Program. Best performed on a treadmill.  This phase consists of walking at roughly 4.2 to 5.2 mph.  You need to be able to walk pain free at this pace before moving onto the next phase.

Phase 2:  Plyometric Routine. This phase consists of  ”controlled” hopping.  The key element of a controlled hop is a proper landing.  Its very important that the ankle, knee, and hip joints work in concert to absorb the shock of landing.  A loud slapping sound while landing indicates poor technique.

In my case, my therapist is having me ease into the hopping exercises by first performing these exercises in a pool with the water line at chest level progressing to waist level.  I subjectively guage my effort level at 50%-75%-100% progressions.  Meaning, that I begin by performing my hopping exercises with the water at chest level at 50% effort, then progress to 75% effort, then progress to 100% effort.  Once I reach 100% effort I’ll move towards the shallow end of the pool and  perform my hopping exercises with the water at waist level, progressing at the same rates.  Once I’ve mastered hopping in a pool I’ll move to performing these exercises on land and start all over again!

The Phase 2 Plyometric hopping exercises consist of:

- Two leg hops in place

- Two leg hops forward/backward

- Two leg hops side-to-side

- One leg hops in place

- One leg hops forward/backward

- One leg hops side-to-side

- One leg broad hop (my therapist didn’t prescribe this exercise for me)

Rest Intervals: 90 secs between sets / 3 mins between exercises

Its anticipated that I’ll be in Phase 2 for approximately 4-6 weeks.

Phase 3:  Walk/Jog Progression. Progress to Phase 3 only after you’ve completed Phases 1 & 2, have no pain with normal daily activities, and the AT no longer hurts when you press on it.  Phase 3 consists of a progression of alternating between walking and jogging.  The ratio between walking and jogging starts with 5 minutes of walking, 1 minute of jogging (repeated 5 times for a total of 30 minutes).  You go through a progression of improving upon the walk/jog ratio ultimately reaching a goal of being able to jog every other day at 30 consecutive minutes.

Phase 4:  Times Running Schedule. This phase marks the final phase of the Return to Running Program.  In this phase you increase the intensity of the jog/run as well as the duration.  Use the 10% rule:  Only increase the weekly mileage by 10% of the previous week.  Eventually you’ll increase the frequency of days you jog/run.

And from here, you’re on your way to full recovery!  Simple enough, right?!

It’s been a while since I’ve posted an update to my blog. My recovery has been moving along and I’m able to almost walk normally (just the slightest gimp at the end of my gait). I’m now going to physical therapy once every two weeks with the goal of returning to running. However I learned a valuable lesson today from my physical therapist who provided me with some good advice about my recovery.

I seem to have recently hit a plateau with my recovery doing exercises consisting primarily of doing several sets of two-legged and single-leg toe raises off of a step (focusing on the downward motion). Not only did I experience a plateau, I just may have pushed myself too hard and compromised my recovery schedule.

Essentially I was doing too much, too soon. I’d go to the gym, workout my upper body, then finish my workout by doing my PT exercises. I noticed that after doing my exercises that my Achilles felt inflamed (swollen, redness, and warm to the touch). The next morning my Achilles would be in so much pain. It took 2-3 days for the pain and swelling to go down before I could resume my PT exercises again. I even iced my AT and took Ibuprofen to bring the swelling down.

When I told my physical therapist about this she just gave me that look, “Hey stupid, slow it down and listen to your body!” She explained to me that with ATR recovery exercises its not a “no pain, no gain” situation. Because the tissue is still healing, I need to balance between too much stress (equals overload and tissue breakdown) and not enough stress (equals tissue atrophy and break down). The right balance of stress equals improved strength and hypertrophy.

According to an article that my physical therapist printed out for me – Return to Running Program by Steven L. Cole, it’s important to use the following principles to gauge whether you are overloading your tissues during PT recovery exercises:

1. Pain
2. Swelling, redness, and/or warmth. Apparently chronic swelling impedes the body’s ability to heal and may actually weaken surrounding tissues.
3. If after performing an activity you find that later your function is limited then you did too much.
4. Pain that occurs earlier on in a program that you performed previously.

My physical therapist refers to exercising to the point of my “tissue’s threshold” without exceeding (overloading) that threshold. Once you hit that threshold then its time to ease back a little and give your tissues a rest for the day.

Today my physical therapist introduced some new exercises involving weights – seated toe raises (two-legged using 45 lbs; single-leg using 25 lbs; 3 sets of 10 reps alternating between two- and single-leg seated toe raises).

For my Return to Running Program, I start with the Phase 1: Walking Program. In Phase 1 I must be able to walk, pain free, aggressively (roughly 4.2 to 5.2 miles per hour), preferably on a treadmill, before beginning the plyometric and walk/job program.

My ATR recovery continues to go very well.  In fact things are going so well that my physical therapist had me cancel one of my sessions last week and has me going to PT once a week for the remainder of this month.  Eventually my PT sessions will be further reduced to once every two weeks until I reach my ultimate goal of returning back to running.  Yesterday my therapist took a few measurements of my range of motion and said everything was excellent.  My AT range of motion is now within the norm!

I’m now working on strenthening my AT and calf muscles in my bad leg.  I’ve been doing calf raises with both feet and lately modified the exercise so that I use both feet on the up motion and only my bad foot on the down motion.  However, today at the gym I was able to do single leg calf raises using my bad leg only! But don’t get excited yet.  I had to use the assistance of my hands by grabbing onto the railing to lighten the load.  I can’t wait until the day I can do single leg calf raises under my own weight.

This week was also my post-op check up with the ortho surgeon.  He inspected the scar site and was impressed with my progress, the range of motion, and the amount of strength of my AT (as little as it was).  He said that I’m still ahead of schedule of normal recovery.  I recall when we first discussed returning to running.  He had told me that it would definitely take at least 9 months.  He then soften that to 6-9 months; then to at least 6 months; and then this week he indicated a minimum of 4-6 months for very light jogging. Cool beans!  I’m also hoping to walk normal again soon.  Right now I walk with a slight limp which tends to get a bit more exaggerated as the day lingers on. Without the props of my crutches or Mr. Boot, I just look like some dude that can’t walk normal.

My next check up isn’t until another 6 weeks.  By then, according to my ortho surgeon, most if not all of the residual swelling should be gone.  I certainly hope so.  I wouldn’t want to get use to wearing compression stockings! LOL

My physical therapy sessions are really paying off.  This week my therapist gave my AT one heck of a work out.  On Tuesday she went through the normal routine of ultrasound and stretching out the range of motion of my AT.  Then she had me workout on a wobble board by balancing myself on the board…using my bad leg only.  My initial thought was that she was totally crazy!  I can barely keep my balance on my good leg on any given day of the week.  I left Tuesday’s session absolutely exhausted and sore.

On Thursday she wasn’t as rough on my AT.  This go around she had me workout on a Pilates machine doing calf raises on my bad leg only as well as simulated jumps while landing on my bad leg.  Both of these exercises felt a little strange at first since this was the first time placing “force” on my AT.  Since the joints in my ankle seems to have full range of motion now, my therapist is beginning to work on strengthening my bad leg.  She modified my calf raises by having me do this exercise on the edge of a step and slowly bringing my heel below the step line (repeat 20 times per set, do 3 sets per session; do 1 session per day).  She also measured the ROM of my AT and said it was at 9 degrees.  I need between 12-15 degrees of motion in order to run again.  So I’m almost there.

My progress has really improved with these exercises.  I’m able to wear my favorite flip flops again and officially throw Mr. Boot into the storage closet!  Walking upstairs no longer poses a problem.  Although walking downstairs still takes a little more effort.

Here are some pics of me doing my calf raise exercises and my new wobble board that I bought just the other day.

I recall watching this video prior to my own surgery.  I can’t get enough of it!!

Yes, I’m pretty sick at times.  LOL.

Check it out http://www.youtube.com/watch?v=0DNeeGuHKGU

Well despite my ortho surgeon’s advice to keep wearing the boot over the next three weeks until my next follow up appointment, I made an executive decision to ditch Mr. Boot for my matching pair of Brooks Adrenaline running shoes. The awkwardness of limping around in my boot was very tiring and was beginning to wear out my “good” hip and knees. However, I still need to work on re-learning the mechanics of walking. So I will remain vigilant in sticking to my PT appointments and doing my home exercises.

I’m getting use to wearing the compression socks, too.  OMG getting into and out of these socks is quite a site.  I have no clue as to how women can deal with wearing stockings and panty hose on a daily basis!  But so far the socks seem to be doing its job in keeping the swelling down.

I mentioned in my previous blog that my physical therapist revised my exercise routine.  She added one new exercise and modified 3 others:

1.  Balance. Attempt to balance on affected leg, eyes open. Practice balance for 1 minute, repeat 6 times.  If too difficult, modify by placing unaffected leg in front of affected leg — heel to toe — like taking a DUI test.  Not that I experienced any of this first hand!

2.  Gastroc Stretch. Stand with affected foot back, leg straight, forward leg bent. Keeping heel on floor, lift big toe up a little bit so that midshift of body weight is to the outside of the foot, lean into wall until stretch is felt in calf.  Hold for 20-30 seconds. Repeat 3 times per set. Do 1 set per session. Do 3 sessions per day.

3.  Soleus Stretch. Stand with affected foot back, both knees bent. Keeping heel on floor, lift big toe up a little bit so that midshift of body weight is to the outside of the foot, lean into wall (or sitting motion) until stretch is felt in calf.  Hold for 20-30 seconds. Repeat 3 times per set. Do 1 set per session. Do 3 sessions per day.

4.  Heel Raise: Bilateral (Standing). Rise on balls of feet. Lower heels slowly over a 6 second count. Repeat 20 times per set. Do 3 sets per session. Do 1 session per day.

Six weeks post-op and I’m ready to ditch the crutches!  Although me and “Mr. Boot” will remain buddies for about three more weeks.  As of today, I’ve been able to walk decently (as well as go up and down stairs) without the assistance of my crutches.  I should also mention that all the scabbing from the incision has sloughed off leaving a nasty looking, but very smooth, scar behind my ankle.  So that’s progress.

I started my physical therapy sessions last Wednesday and will continue with the PT sessions twice a week for at least the next eight weeks.  OMG, I thought I was going to die after my PT session yesterday.  My therapist really gave my AT quite a workout with all of the ROM exercises and manipulation.  She also rubbed my AT along the scar line and I just about jumped out of my skin!  Not only did the rubbing hurt but it felt like she was about to rip apart the incision.  But fear not, my ortho surgeon assured me that would not happen…whew!  She also had me practice the first motion of walking using a cable behind my AT and about 15 lbs of weight along with a wedge that she placed underneath my heel.  This exercise was a bit painful, too.  Why can’t the PT massage feel like a nice soothing deep tissue or Swedish massage?  No pain, no gain, I guess.  But I must admit that the PT sessions are very effective and have advanced my rehab progress tremendously.  My long term goals with PT is to be completely full weight bearing over the next 8 weeks and to return to recreational activities in 6-9 months.

Today I had a follow up appointment with my ortho surgeon.  He said everything is looking great and that I appear to be ahead of schedule.  His goal for me over the next three weeks is for my affected AT to have full flexibility similar to my non-affected AT.  If I can accomplish that then I’ll be able to get rid of Mr. Boot for good…or at least I’ll begin transitioning to wearing two shoes.  My ortho surgeon also prescribed compression socks for me to wear (replacing the ace bandage that I’ve been wearing since the surgery).  The compression socks will help keep the swelling down.

After searching unsuccessfully for a physical therapist located near my home with immediate openings in Virginia, I ended up choosing a physical therapist located in the District.  Today was my first visit to see the therapist and was impressed with my initial appointment.  My therapist worked on my Achilles quite aggressively which is in sync with my orthopedic surgeon’s aggressive approach.

She poked, prodded, compare/contrast the good and bad Achilles, and took a bunch of measurements.  In the end she told me that my Achilles has a flexibility of -8.  However, in order to return back to running the flexibility of my Achilles needs to be around +15.  It looks like it’ll be a long road ahead of me.

She assigned me 8 isometric exercises to do at home and while at work sitting at my desk.  She’ll be measuring for progress at each of my follow up visits over the next two weeks and will be able to easily tell if I’ve been slacking off.  The expectation is that the flexibility of my Achilles will improve at each visit.

Up until now, I’ve only been doing one stretch prescribed by my orthopedic surgeon.  Both my therapist and orthopedic surgeon told me that the more my Achilles becomes flexible, the faster I’ll be able to begin to walk and become full weight bearing.

The biggest surprise to me is that I’ve been stretching out my Achilles and calves to the point of slight pain, yet my therapist (and orthopedic surgeon) really want me to push a little harder! All I can say is that its not easy tolerating that uncomfortable, painful feeling.  But I guess what hurts makes you stronger….whoops! I think I told myself this very same thing just before I ruptured my AT!!

The protocol my therapist assigned me is as follows:

1. Isometric Inversion. Sitting with leg crossed, press inner border of foot into hand. Hold 6 seconds. Relax. Repeat 10 times. Do 2 sessions per day.

2. Isometric Eversion. Sitting with leg crossed, press outer border of foot into hand. Hold 6 seconds. Relax. Repeat 10 times. Do 2 sessions per day.

3. Isometric Plantar Flexion. Using a strap around the ball of the foot (yoga strap, dog leash, belt), press foot while providing resistance with the strap. Hold 6 seconds. Relax. Repeat 10 times. Do 2 sessions per day. Do this exercise with the foot bent at 90-degrees, 60-degress, and 45-degrees.

4. Sitting Toe Raise. While seated, raise toes off floor. Keep heels on floor. Repeat 20 repetitions per set. Do 3 sets per session. Do 2-3 sessions per day.

5. Sitting Heel Rise. While seated, rise up on the balls of feet. Repeat 20 repetitions per set. Do 3 sets per session. Do 2-3 sessions per day.

6. Single Leg Toe Curling. With foot resting on towel, slowly bunch towel up as you curl toes. Repeat 20 repetitions per set. Do 3 sets per session. Do 2-3 sessions per day.

7. Soleus Stretch. Standing with both knees bent and involved foot back, gently lean into wall until stretch is felt in lower calf. Hold 20 seconds. Repeat 3 times. Do 2 sessions per day.

8. Gastroc Stretch. Keeping back leg straight, with heel on floor and turned slightly outward, lean into wall until a stretch is felt in calf. Hold 20 seconds. Repeat 3 times. Do 2 sessions per day.

Wish me luck!