Tuesday, July 17, 2007

How I Ruptured my Achilles Tendon

It was January 14, 2007 and I was playing tennis with my niece when I ran to catch a drop ball near the net. As I was sprinting toward the ball I suddenly felt a sharp pain behind my right ankle, like if somebody had hit me really hard with a baseball bat. I fell down and looked around, but didn't see anybody close to me. When I stood up I could barely walk. This is what happened:

My heel was numb and I couldn’t push myself forward nor stand on tip toes. I applied some ice, limped to the car and drove back home the best I could (I had to push my whole leg against the gas pedal pressing my right hand against my knee, as my foot wouldn’t respond).

I was taken to the emergency room of the closest hospital where they took some X-Rays, gave me some pain killers and, sent me home with a recommendation to see a specialist the next day. Early Monday, I went to see the orthopedist and after performing a simple Thompson test. You can see a similar test in here:


He immediately diagnosed Achilles tendon rupture and scheduled surgery for the 26th (12 days after the injury).

In the following few days I started reading about Achilles tendon fractures to familiarize myself with the problem and the possible treatments. One of the first (and best) articles I read was this one; it mentions the “middle age weekend warrior” playing tennis or basketball as the most at risk group.

In my case, I was playing tennis after almost five years, and hadn’t exercised for at least the last two. I jumped straight to the court and started playing, without warming up or stretching. Big mistake.

Monday, July 16, 2007

The R.I.C.E. Principle

With all acute foot injuries, especially Achilles tendon inflamation or ruputre, follow the RICE principle to reduce swelling, pain and inflammation. I followed this routine from the time of my injury until surgery day:

Rest- Try to walk as little as possible, even if you’ve been fitted with a walking boot. If possible walk with crutches to reduce or eliminate weight bearing.

Ice- Use an ice pack for 20 minutes every two to three hours during the first 72 hours.

Compression- Use an ace wrap on the ankle. Start at the bottom of the toes and wrap up to the knee.

Elevation- Keep the injured ankle above the level of your heart when sitting or lying down.

Sunday, July 15, 2007

The CAM Walker or Boot

After diagnosing the Achilles tendon rupture, my doctor gave me a CAM Walker, an adjustable boot with metal rods on the sides and Velcro straps to ensure a tight fit to the leg. This is how it looks like. Since this device immobilizes the foot and ankle, it prevents any pressure or strain on the broken tendon and the surrounding muscles, and allows you to walk safely.

The doctor told me that I would also use the same CAM Walker after the surgery, instead of a regular cast. Some people don’t like this, because the CAM Walker is very heavy. However, since you can control the pressure with the Velcro straps, it is a better option than the cast while you still have a fresh scar with stitches.

My boot didn’t have angle settings; it was just fixed at 90 degrees. Some doctors like to use an adjustable boot that allows the foot to be positioned at different angles so that they can start by placing the patient’s foot pointing slightly down, and move gradually to 90 degrees (see picture to the left). Supposedly, this allows for a more gradual healing of the tendon.

My doctor didn’t think that was necessary and gave me a boot that would position my foot at 90 degrees immediately after the surgery.

Saturday, July 14, 2007

The Days Before the Surgery

Since the injury was on my right foot, the bulky CAM Walker pretty much made driving impossible, so I was put on disability and started to work from home. Most of my work is done by email with my laptop and I have a wireless connection to the office, so that helped. For a moment, I thought of getting this left foot accelerator but it costs more than $300 and it would have been too much of a temptation especially during the first crucial weeks when the best you can do is rest.

I used the week before the surgery to finalize any pending task or project around the house, like fixing little things, organizing my papers, getting a hair cut, and setting up my home office. I also organized my room, by putting a few tables and chairs to have things handy, and rearranged the bathroom to minimize clutter and facilitate movement.

At the same time, even though it was not necessary, I started moving around in crutches, for practice. I figured that if I was going to fumble and stumble with the crutches, it was better to do it then instead of after the surgery, when bearing weight on the injured foot is absolutely prohibited for several weeks.

During the night, I took the boot off to sleep more comfortably, knowing that for several weeks after the surgery I wouldn’t be allowed that luxury.

I also used the days before the surgery to iron out all the details with the insurance. Make sure that every procedure you will go through is covered under your plan. I neglected one minor detail: to check if the outpatient center where the doctor chose to perform the surgery was an “in network” facility. I assumed it was, but it just happened it wasn’t, and I had to shell out a $400 out-of-network co-payment. So don’t assume anything: call and make sure.

Finally, I thought it would be a good idea to find a support group of people who had gone through the same experience, so I started looking for forums or discussion groups where I can read and talk about the AT post surgery process. I found Simon Barratt’s blog to be extremely useful and informative, with plenty of helpful people who had recently had AT surgery and were going through the different stages of rehab. At the time of this writing, that blog had more than 1,800 entries so you will learn first hand how real people just like you cope with this experience.

Friday, July 13, 2007

Pre Surgery Tests

To be admitted to surgery, I needed to complete some tests. Since the Achilles surgery is done under general anesthesia, they required a blood and urine test, an electrocardiogram and several chest X-Rays. Overall, it took me one full morning at my primary care physician’s office.

Thursday, July 12, 2007

Achilles Tendon Surgery: Hospital vs Outpatient Center

Since this was my first surgery involving general anesthesia, I was a bit concerned. I was also somewhat concerned about the fact that the operation would take place in an outpatient center instead of a regular hospital.

In reality, outpatient centers are as well equipped as hospitals to perform surgery, but at that point I was not really familiar with them. So I did what I always do when I need to know more about something: I went online and started doing research.

I found a great website that explains at length everything you need to know about outpatient surgery. Here is the link: Outpatient Surgery Article. By reading it, I learned that 60% of the surgeries performed in the US are now outpatient, and that the percentage will likely increase to 75% over the next decade.

The article also explains, step by step, every aspect of the outpatient surgery procedure. This was great, because when I actually went to have my surgery I knew exactly what to expect. That took a lot of the anxiety away and made for a more pleasant experience.

Wednesday, July 11, 2007

Achilles Tendon Surgery: Facts About Anesthesia

I also found a very good resource about anesthesia that explains everything you need to know about anesthesia: the different types, when they are used, how they work, and the pros and cons of each of them. Achilles tendon surgery is performed with general anesthesia, so this site will familiarize you with it and hopefully remove any doubts of fears you may have, especially if this is your first time. I know it helped me a lot.

Tuesday, July 10, 2007

Types of Achilles Tendon Surgery

I also did some reading on the Achilles surgery itself and found out that there are basically two types of surgery: open surgery and percutaneous surgery. The difference is that the percutaneous method requires only a few incisions, so there are fewer complications in the skin healing process. However, since the doctor will have less visibility of the area, the potential for nerve damage is greater than in the standard, open surgery. This article also gives you a good overview of the two methods.

Open surgery requires a larger incision, but it leaves the area wide open for the surgeon to work with more ease, therefore reducing the possibility of nerve damage. This site explains the open surgery technique in detail and shows some pictures (not for the squeamish).

Open surgery can also performed using several grafting techniques (using other tendons and materials to reinforce the Achilles tendon in the repair site).

In my case, I had the standard open surgery (non-percutaneous).

Monday, July 9, 2007

The Day of the Surgery

My surgery was scheduled for a Friday, at 10:00 am at an outpatient center. The time was very convenient since it was not too early and it still allowed me to be back home by more or less 5:00 pm the same day. The whole thing was pretty straightforward and much less frightening than I had anticipated.

Upon arrival to the outpatient center they fit me in a surgery robe and assigned me a bed where I was plugged into a heart rate monitor and given IV fluids. I was also interviewed by the anesthesiologist who explained the whole procedure. After about an hour, during which nurses frequently stopped to chat and joke a little bit to release the tension, they shaved my leg and took me to the operating room.

Being my first surgery I have to say that seeing the operating room was a pretty intimidating moment. There’s plenty of complicated equipment around, and the light is very, very strong. And there, in the middle of it all is the operating table. At that point it is hard not to feel a little bit scared. Fortunately they gave me a plastic mask to put over my nose and mouth and told me to breath slowly.

The next thing I remember is opening my eyes after surgery, already in the recovery room. I noticed that I had the same walking boot I had before the surgery (like my doctor had said) but this time I also had a heavy bandage underneath it. They finally gave me some apple juice, made me go to the bathroom, sign my discharge papers and let me go home.

Once home, I crutched my way to bed, had something to eat and checked my emails in my laptop. For precaution, I took a couple of Vicodin for the pain, which was not so severe. I have to tell you that I was very concerned about the pain, since I had read horror stories about unbearable pain in several blogs. However, I never really experienced excrutiating pain, to the point that by the third day I decided to discontinue the Vicodin.

Sunday, July 8, 2007

The Long Road to Walking Again: Rehabilitation Protocols

My doctor told me that it could be around three months before I was able to start walking, and maybe six months or more to walk normally. Actually, the progress you make depends on many things: the severity of your injury, the amount of time you wait to have surgery, the quality of the surgery, how rigurously do you follow the rehabilitation suggestions, how old or how fit you are, and how disciplined you are during the physical therapy stage.

Aside from that, there are several “rehabilitation protocols”, basically a timeline or sequence of activities from the day of the surgery to return to normal physical activity. Most protocols consider six months the usual time to walk more or less normally and perform not too demanding excercises, and about a year to return to regular sports activities. The rehabilitation protocol you will follow depends mostly on your doctor, who may prescribe a very conservative or very aggressive protocol.

The main difference is the amount of time you will be non-weight-bearing. The NWB period should basically serve to achieve a delicate balance between the tendon healing and avoiding the excesive weakening of the calf and leg muscles due to inactivity. Some doctors advocate extended NWB periods (like my doctor, who prescribed 9 weeks of NWB), while others tend to think that by the third week the tendon is pretty much healed and weight bearing should start, so that the leg muscles don’t have the change to weaken too much.

I am here including links to a more or less normal/conservative rehabilitation protocol, and an aggressive protocol advocated by James S. Keene after a "turn down" fascial grafting surgery.

Saturday, July 7, 2007

What Does Non-Weigh-Bearing (NWB) Really Mean?

There is considerable anxiety among AT patients about what non-weight-bearing really means. Basically, the best way I can put it is that your injured foot must not be used when walking, not even with crutches. However, there are some things you can do, like resting your foot on the floor while sitting down.

The safest way to rest your foot on the floor is by having your heel touch the floor while your toes point upwards, at an approximately 45 degree angle to the floor. This way you minimize the contact area. I would not advice to lay your foot flat on the floor, as this tends to increase the contact area and makes the weight of your leg press against the bottom of your foot (technically, weight bearing).

Most likely, you will be required to be NWB for a period between 3 to 10 weeks, depending of the nature of your injury and how aggressive the rehabilitation protocol used by your doctor is.

During the NWB period, It is very unlikely that you will not face at least a minor incident that may cause you to involuntarily put some weight on the injured leg. In my case, there were three of those instances:

The first one occurred 2 weeks post-op, getting out of my car. I had stepped down and had put my hand over the back door, which was open, to keep my balance. My wife closed the door without noticing that my hand was there, so instinctively I removed my hand, lost my balance and stepped on my bad foot. Fortunately, nothing happened.

The second incident occurred at 4 weeks post op. It was raining and my right crutch slipped, making me step hard on the floor with my right foot to prevent falling. Other than a tingling feeling, like needles sticking in my lower leg (probably a reaction of the dormant muscles to the sudden pressure) nothing bad happened.

The third time, it happened at 6 weeks post op. My crutch got stuck while I was stepping out of a train and I had to step really, really hard with my bad foot to avoid falling flat on my face. The pain was severe, like needles again, but lasted only a few seconds. Back home I removed my CAM walker (boot) to check the tendon, and it was working normally.

My conclusion is that even though you may take every precaution not to step on your bad foot, there will always be one or two instances in which something will happen that will make you bear some weight. However, the good news is that the boot though (and certainly a cast too) keeps your foot in a position that doesn’t allow putting undue stress on the tendon, so as long as you are wearing it you should be well protected against any such minor incident.

Friday, July 6, 2007

Setting Up Your Bathroom and Taking Showers

My bathroom is kind of small, which in this case helped. To make it as user friendly as possible while non-weight-bearing, I brought in a chair and placed it at equal distance from the toilet, sink and bath tub. That way I could go from the toilet to the sink and to the sink to the bath tub just by leaning on or kneeling on the chair. By appropriately placing the chair, using the sink is very easy since you can just place your bad leg’s knee on the chair while keeping your good leg on the floor.

I also got a small stool from a medical supply store to be able to take showers sitting down. This chair is very stable and simple: it has a wide sitting area with two handles on both ends so that you can lift yourself easily.

Transferring myself from the sink area to the bath tub was a two step process. First, I sat on the border of the bath tub (make sure you place a towel, just in case the bath tub is wet. You don’t want to trip at this point). Once safely sat facing outside the bath tub, I then grabbed the stool by the handles with both hands and slowly lifted myself while keeping the good foot on the floor until I was safely sitting on the stool. Next, carefully I carefully moved my good leg inside the bath tub, leaving the bottom half of my injured leg outside. Finally, I closed the shower curtain over the top half of my injured leg. At this point, positioned at a 90 degree angle to the shower head and facing the shower curtain I was ready to take a shower.

For extra precaution, just in case water leaked out of the shower, I wrapped a dry towel around the boot. Once I had taken the shower, I reversed the procedure to get out. It is kind of uncomfortable at the beginning, but after a couple of weeks you should get the hang of it.

There are all sorts of stools and bath tub aids out there, including something called a “transfer station” (basically a long, bench-like stool that rests partially outside the bath tub so you can sort of slide your way inside the bath tube). However, the simple stool I used did the trick for me and I didn’t need more sophisticated equipment.

Thursday, July 5, 2007

How to Use Crutches

Using crutches is pretty straightforward. Most people believe that you must press your weight against your armpits, but that is wrong. The top of the crutches must not touch your armpits. Instead, they should rest approximately 1 ½ inches below your armpits when standing straight.

Your hands must have a tight grip on the crutches and your arms must be slightly bent. Your arms and hands will be absorbing your weight.

To start moving, lean your body slightly forward and put forth your good leg. Follow with both crutches instead of your bad leg. The trick for the smooth operation of the crutches is to lean your body slightly forward immediately before taking a step.

To go up stairs, place both crutches firmly on the floor next to you. Then, lean forward a little bit and immediately (and very fast) move your good foot up to the next step. Then, bring up the crutches and position them firmly on the floor next to you and repeat the procedure. Leaning slightly forward before taking the step is very important, since not doing so may cause you to fall backwards.

To go down stairs, place both crutches firmly on the next step below you and move your good foot down very, very fast. Then, repeat the procedure.

I don’t recommend to go up and down stairs that are bigger than just two or three steps. If you absolutely have to climb large stairs, it is better to do it sitting down.

Finally, at least at the beginning, it is good to always have someone next to you, to help you keep your balance just in case something doesn’t go smoothly.

After a few weeks of crutching you will start to notice that your upper body (arms, shoulders and chest) is stronger and more toned, without doubt a nice side benefit in exchange for the uncomfortable nature of crutches.

Since one of the most annoying aspects of crutches is the fact that you can't use your hands for other tasks, some companies have come up with alternatives to traditional crutches, and have developed hands-free crutches. I've seen a couple of them being discussed in other forums. One of them is the iWalk-Free crutch, which looks more like a prosthetic leg and promises hands-off mobility. See the picture here (click on the picture for more information):

iWALKFree Hands Free Crutch

Initially, I thought it was a cool idea, until I saw the price (slightly less than $400). In the end, I decided not to spend the money. However, if your insurance would pay for it and you would like more mobility than what traditional crutches allow you, it can be a good option.

The other one is a Knee Walker. See below (click the picture for more information):

Drive Knee Walker - Standard (300 lb. weight capacity)

It allows you to place your knee in the platform and roll away. I didn't buy it because it was also about $350 (by now you probably may have noticed I'm cheap!). But, as I said before, if your insurance pays for it, or you value mobility more than the bucks it costs you may decide to get it.

Wednesday, July 4, 2007

The First Three Weeks Post-Op: Rest and Elevation

During the first three weeks post op you need to follow the R and E of the R.I.C.E. principle. Rest and Elevation during this crucial time are absolutely necessary for proper healing of both the incision wound and the tendon. I took this very seriously and for the first three weeks I stayed mostly in bed with a pillow under my leg. I figured that the less I moved the less my chances of tripping and involuntarily putting weight on the injured foot. The elevation made sure that there was adequate blood circulation in the affected area (known for its poor circulation and tendency to swell). Good blood circulation accelerates healing and prevents the formation of blod clots, which can be fatal.

During these initial three weeks I had the luxury of having my wife bring me breakfast to bed every day, and my parents coming over at lunchtime with tapperwares full of healthy, home cooked meals. I couldn’t have asked for better caring conditions. They were great during my whole healing process but really invaluable during this initial period.

I credit to this rigurous regime the fact that I had absolutely no problems with my scar (no infection, itch or pain) and no tendon pain. By the third week, I could feel the tendon healing nicely (the calf muscles moved slightly when slightly bending my toes down and pressing against the boot, which is a signal of the tendon doing what it is supposed to do).

During this time when boredom can set in, so make sure you have a laptop with a wireless connection (if you are an avid Internet surfer as I am) or at least an ample supply of good books and magazines.

Finally, to be able to sleep comfortably, I loosened up the bed sheets and rolled them up so that the foot could rest on the pillow without the weight of the sheets and the comforter on top of it (the boot is already heavy… you don’t need any aditional weight).

Exactly two weeks after surgery, the doctor removed my stitches (actually, they were staples). My incision was fairly large (about 6 ½” inches) so the process was not much fun. Fortunatly it was painless. I could feel the stitches being pulled out, but it didn’t hurt. The incision had healed wonderfully, undoubtedly because of my discipline regarding rest and elevation during the first two weeks. The removal of the stitches meant that I had reached one big milestone: I could start taking showers with both legs inside the bathtub, as the wound could now get wet with no problems.

Tuesday, July 3, 2007

Weeks 4 to 9: Waiting it Out

Between weeks 3 to 9 nothing remarkable happened. Rest and elevation continued religiously during weeks 3 and 4, and I started moving more after week 4, going out to the movies, Barnes & Nobel, Starbucks, etc., while always elevating the foot at home. I started going to my parents’ house for lunch instead of having it catered in. My dad would pick me up at noon and bring me back home at 2:00 pm so I could continue working.
I didn’t go back to the office until week 6, when I was already finally feeling confident about the healing process, and I was pretty good with the crutches. At first, I went to the office twice a week (my dad and my wife would do the 45 minute trip in the morning, and a co-worker would drop me off in the evening). I worked the remaining three days of the week from from home. By week 7 I increased the frequency of days in the office to 3 times a week.

I had an appointment with the doctor at week 7, for which I had the high expectations of starting weight bearing and maybe also physical therapy. My doctor is pretty conservative so he said “not yet”, and gave me two more weeks of N-W-B before allowing me to start putting 50 pounds of weight at week 9.

Monday, July 2, 2007

Weeks 10 to 12: Accelerating Weight Bearing (and Driving)

While the doctor had only allowed me to put 50 pounds of weight (still with the boot), I started testing my limits and gradually putting more and more weight. If you have the boot on you are pretty safe, since it will not allow any extension of the tendon. There would be moments in which it felt as if I was putting one ton of weight on the injured leg, because it was still very week. I could also feel a tingling sensation (like needles) if the weight was too much. I let those “needles” be my measure of when I was putting down too much weight. By week 10 I was already taking a few steps with one crutch only (since my injured foot was the right one, I used only the left crutch). After a couple of days I started trying some steps with no crutches, leaning on tables or walls. Two or three days after that, I was already walking without crutches. By week 12 I had another appointment with the doctor who, seeing that I was already full weight bearing (with the boot) gave me the OK to start physical therapy.

Once the doctor allowed me to start putting weight, I decided it was time to go back to driving. Since I was still on the boot, I used my left foot to both accelerate and break (I drive an automatic). At the beginning it felt weird but with one weekend of practice I was ready to take the plunge. I don’t know if it is legal or not to drive with the left foot, but I figured that I could do a better job with my left foot than many of the 85 year olds that you see driving daily here in South Florida. In fact, I got so comfortable braking with my left foot I still do it now (six months post-op) out of habit.

Sunday, July 1, 2007

Weeks 13 to 20: Physical Therapy and Ditching the Boot

Immediately after week 12, I started physical therapy, which I continued for 27 more sessions (three times per week, one hour each time). The first day was the hardest, as I was instructed to remove the boot and take my first steps without it in more than three months. Needless to say, I limped considerably, with a flat footed gait, as if I still had the boot on.

Little by little, as the tendon gained flexibility and strength, the limp would diminish (although to this day, six months after surgery, I still limp immediately after waking up and when I don’t have a shoe on). After the first week, I started wearing a shoe around the house instead of the boot, and after about ten days, I started wearing the shoe outside too. My therapist said that if I was already wearing the shoe and felt comfortable there was no need to go back to the boot (major milestone!... no more boot entering week 14 post-op).

Something I observed during therapy is that the progress is very fast in the first two weeks, and then it gets slower afterwards. This is only normal, since after been immobilized for such a long time, the initial excercises have a big impact. In order to keep improving, it is necessary to keep the discipline and increasing the frequency/weight of the excercises.

I always started my therapy with 10 minutes on the stationary bike. This served the purpose of loosening up the tendon and stretching it a little bit, making the following excercises easier. Remember, you're not doing cardio, so don't try to pedal too fast. I was doing around 40 RPM, trying not to put too much pressure in the tendon.

After the bike, I usually did the Biodex Dynamometer (see picture to the left, click to enlarge), for passive range of motion (PROM) excercises (15 minutes per session).

Basically, I sat down in the machine with my right (injured) leg extended, while the therapist adjusted the seat and strapped my foot to a metal platform that would move slowly back and forth, generating plantarfexion and dorsiflexion. Since this is a PROM excercise, it is the machine that does the work, not you.

The idea is to progressively increase both plantarflexion and dorsiflexion angles until a normal range of motion is achieved (getting there took me about three weeks). After that, I used the same machine for active range of motion exercises, meaning that this time I had to move the foot myself. The machine can be set up at different levels of resistence, to make movement harder each time.

One of the simplest and most important exercises you can do is using the Thera-Band bands. These bands come in different colors, each of them representing a different resistence level. I started off with the green, and then moved to the blue (the yellow is softer and usually recommended when you are just starting therapy). You can see the bands below:

20050 Band-B Theraband 6yd Roll Bl

Basically, what you will do with these bands is a group of four excercises called "Resisted Ankle Strengthening", encompassing plantarflexion, dorsiflexion, inversion, and eversion. The excercises are fairly simple and you can see how to do them in this excellent video (you need to Quicktime to view them):

Another excercise that I found very helpful is the Achilles stretching using the ProStretch (see below):


The ProStretch is a round-shaped accessory used to stretch your calf muscles and Achilles tendon. Basically you position your foot on the ProStretch and then roll it backwards (making your toes point upwards). If you keep your leg straight, you will be stretching your calf muscles.

If you do what I described before, but bend your knee a little bit until you feel a light pull on the Achilles, you will be stretching the tendon. That is the idea. I initially did three repetitions of 15 seconds each, and now I do five repetitions (I purchased the ProStretch to use at home every day).

I also did proprioception excercises. Proprioception is "the process by which the body can vary muscle contraction in immediate response to incoming information regarding external forces". Basically, I was instructed to stand on one foot for 30 seconds at a time on top of one of these special Thera-Band cushions:

23305 Theraband Stability Trainer Firm, Green

At first, I used the green one (more firm), and once I felt comfortable I moved to the blue one . With this excercise the idea is to re-train your muscles to "remember" how to react when you slightly lose balance. This is very important in order to regain confidence when starting to walk again.

The Six Month Mark

After six months of the operation, everything's going fairly well. I still have a limp when I get up from bed early in the morning, but it gradually goes away (it takes about 15 minutes). I still have to wear comfortable shoes (I still can't wear shoes that are too hard or rub the heel area). I also have to wear socks that are either very low or very high (basically, the elastic band in the socks must not fall within the scar area). Aside from the rehab excercises, I have started to swim and "jogging" inside the pool. I hope to start jogging normally soon.

Saturday, June 30, 2007

Share Your AT Experience

Please feel free to join our AT rupture discussion by leaving a comment below. If you want, you can also read the chronicle of my Achilles tendon rupture and recovery.