Thursday, May 1, 2008

They Say Time is the Fire in Which We Burn

Here is a general time line of events for my injury.

2008

May 1:
147 days post-op. Nothing new to report. Continue with stair climber and elliptical machine. I have been avoiding jogging due to the swelling I experience from running. I am now only going to physical therapy twice a week. My therapist believes by the next doctor’s appointment I will not need any more physical therapy. My tendon continues to nag me every now and again. Some days it feels fine and others it feels like I have tendonitis. I continue to lift weights, concentrating on my calves, hamstrings, and quads.

April 17:
133 days post-op. Nothing new to report. I continue to work on the stair climber. Along with squats and lunges, I have been slowly increasing the weight on my lunges. I am lunging with a 25 pound weight in each hand. I am now able to stand to do a unilateral calf raise (fancy speak for stand on my toes with the bad foot). I cannot not hold the calf raise for more than a second, but I can do it. Side note: My surgeon stated the tissue is healed by 8 weeks. However, since the muscles are weak/atrophied and inflexible there is a risk of re-rupture. The surgeon stated the tissue needs to mature, and that takes up to one year. After I am finished with physical therapy I will need to continue to work on the strength of my calf, quad, and hamstrings muscles to reduce future injuries. Physical therapy, to date, has been nothing but flex and strength training exercises. As my surgeons "six month guarantee" date approaches I am beginning to feel more confident on the surgically repaired tendon.

April 4:
120 days post-op. I began running on the treadmill. A major milestone. I have also been doing calf raises (both legs), squats and lunges. As physical therapy becomes more aggressive, I have noticed how out of shape I have become. Just doing several sets of lunges leaves me winded and a sweaty mess. I have also been instructed by my therapist to work on the stair climber. My left calf is still much smaller than my right, and also has a lack of definition that my right calf has. I was assured by my physical therapist once I begin aggressive weight training on my calf it will return to normal size. I also have to ice my tendon constantly. With the aggressive physical therapy my tendon swells fast.


March 19:
It has been 104 days since my surgery. The tendon still fells stiff in the morning. The stiffness slowly disappears throughout the day. I have also noticed if I get up and start walking after sitting down for a long period, the tendon is stiff and I have a slight limp for the first couple of steps. As far as my physical therapy goes, I am still working on flexibility and balance. I am almost able to bend my injured foot as well as my healthy foot. I have just started working on strengthening the calf. My physical therapist has given me therabands (colorful rubber bands) to strengthen my calf muscles. I sit down and wrap the rubber band around my foot and just start flexing my foot. I am still not allowed to run nor do any high impact activities. I have recently moved from the stationary bike to the elliptical machine. That’s some improvement. At least I can break a sweat now.

March 14:
Doctor’s appointment. 99 days post-op. Doctor again tested strength and flexibility of tendon. Doctor was pleased with progress and stated I can begin to start more aggressive physical therapy starting in April. Next doctor’s appointment in two months.

March 3:
It has been 87 days since my surgery. I am almost able to walk normally. I still have the slightest limp. I am sure no one would be able to notice except for me. I am starting to feel guilty parking in the handicap parking spaces when I am able to hop out of my car with ease. I see the older people giving me the evil eye. However, when I see how far away I have to park when it’s raining/snowing out and there is a full parking lot; I don't feel as bad. **SIDE NOTE: Make sure you get a handicap parking placard from your doctor. Those things are priceless.** Physical therapy still includes working on my Dorsiflexion (bending my ankle) It has improved greatly, but it is still not to the point of my normal tendon. I am still unable to jog/run. I have started controlled squats during my physical therapy visits. Balance is the big area my therapist is concentrating on right now. Standing for long periods of time on the surgically repaired foot is a big problem. The reason being since I have not used the foot for over three months the muscles and nerves have "forgotten" how to fire properly, hence the re-education/therapy.

February 14:
70 days post-op. First physical therapy appointment after playing almost two weeks worth of where's the fax with the insurance company and rehab clinic. After the first appointment, it is now that I realize how much work is ahead of me to get back to the level of where I was before the injury. The therapy included an ultrasound massage, electrodes hooked up to my leg, and manual manipulation of the foot. I was given a list of movements to work on during my rehab process. The physical therapist stated the first few visits would be him just moving the foot around to loosen up the tendon. Later therapy appointments will include re-educating my calf muscles while strengthening and conditioning them. Reports on rehabilitation progress will continue to be posted.

February 1:
Doctor's Appointment. 57 days post-op. Doctor tested strength and flexibility of tendon. Doctor gives the okay to slowly wean off the boot! Doctor prescribes six weeks of physical therapy. Next appointment in one month.

January 23:
Progress Report - 48 days post-op. I can now get around without crutches. Crutches are only used when out shopping or any other time that requires me to walk long distances.

January 11:
Doctors Appointment. 36 days post-op. Given the okay to start putting limited weight on my foot (with the boot on). Doctor believes no more crutches should be needed by February, 1. Doctor stated physical therapy will be started after February, 1 date.

2007

December 24:
Doctors Appointment. 18 days post-op. Cast removed; replaced with the Boot - no weight bearing -

December 6:
Surgery (Doctor stated the operation was 45 minutes) - no weight bearing -

November 30:
Met with primary care physician and orthopedic surgeon. Surgery date scheduled.

November 29:
Ruptured left Achilles tendon.

I will be periodically updating this post.

Wednesday, March 19, 2008

You must have heard of me! Come on! Rudabaugh!

Just a little trivia. Famous people and athletes who ruptured their Achilles tendon:

"The Rock" aka Dwayne Johnson
Dominique Wilkins
Vinny Testaverde
Elton Brand
Takeo Spikes
Todd Pinkston
Christian Laettner
Boris Becker
Yeremiah Bell
Donovan Bailey
Voshon Lenard
Jon Jansen
C├ędric Carrasso
Reggie Hayward
Gabe Kapler

This is just a small list. If you know more please post.

We mock what we don't understand.

Here is an article I read about the surgical technique of repairing the Achilles tendon.

The patient is placed in the prone position with both prepped feet dangling from the end of the table. By placing the table in Trendelenburg, the feet receive less blood flow. An 8-cm to 10-cm longitudinal incision is made just medial to the Achilles tendon. A posterior lateral incision would place the sural nerve at risk and a mid-posterior incision can result in suture interference from the tendon repair site. After dissecting through the subcutaneous tissues, the paratenon is cut longitudinally with Mayo scissors. As the ruptured ends often have a "mop-end" appearance, some surgeons will wait one week before repair in order to allow the ends to better consolidate. After juxtaposing the ends, the tendon is sewn together with non-absorbable suture via a Krackow or Bunnell stitch. Prior to tying the suture ends, the tendon's dynamic resting tension is optimized by comparing it with the control side. A circumferential stitch is used to further strengthen the repair site. After closing the paratenon, the plantaris fascia can be fanned out over the repair site to help prevent adhesions with the undersurface of the skin. The subcutaneous tissue is then approximated with absorbable suture and the skin sewn together in a nylon mattress fashion. A fasciotomy of the deep posterior compartment can facilitate closure in cases with excessive skin tension. This allows for improved closure of the paratenon as well.

Despite the resurgence of the conservative camp in the 1970s, surgery has been the first choice of treatment for Achilles tendon ruptures in young fit individuals since the late 1980s. Advances in surgical techniques and new postoperative rehabilitation protocols have resulted in studies showing the advantages of direct tendon repair. With conservative treatment, extensive scarring often fills the gap between the torn tendons. This leads to a lengthened tendon, which, in turn, leads to decreased push-off strength. In separate studies, Helgeland and Inglis and colleagues showed that surgical treatment of Achilles tendon rupture resulted in increased strength. Cetti and colleagues and Haggemark independently showed that direct repair resulted in less calf atrophy when compared with non-surgical treatment. Mendelbaum and colleagues showed that those undergoing direct repair lost only 2.6% of their strength when undergoing isokinetic testing and that 92% of athletes were able to return to their respective sports at a similar level at 6 months postoperatively. Cetti and colleagues also showed a higher number of patients returning to their pre-injury athletic level. In addition, surgical repair appears to significantly increase the strength in those suffering re-ruptures. Those treated surgically for the second time increased their level of strength by 85% compared with a 51% strength gain in those treated conservatively.

Perhaps the most well known benefit of surgical repair is the decreased re-rupture rate. Despite favoring nonsurgical treatment, Nistor noted that those treated conservatively had an 8% re-rupture rate while those treated surgically had a 4% rate. Recent studies show an even greater difference. Cetti and colleagues reported re-rupture rates of 1.4% 13.4% for surgical and conservative repair, respectively. In a meta-analysis by Kellam and coworkers, re-rupture rates were found to be 1% and 18% for surgical and conservative repair, respectively. Even more impressive is a study by Inglis and colleagues who reported that none of the 44 patients receiving direct repair re-ruptured, whereas 9 of 24 patients treated nonsurgically did re-rupture.

In contrast to Nistor's 1981 study, more recent studies show an increased complication rate in those treated conservatively. One prospective randomized study reported complication rates of 11.8% in patients treated surgically vs 18% for those treated nonsurgically; 96.6% of the complications in the surgical group were considered minor. Leppilehti and coworkers noted that complications related to surgery did not significantly influence the long term outcome as most of them were minor wound healing problems which eventually healed.

Increased operative treatment also leads to more experience in treating complications effectively. For example, it is now shown that physical therapy can overcome many of the problems associated with adhesions between the repair site and the skin. Moreover, the vast majority of superficial wound infections can be treated effectively with limited weight bearing, oral antibiotics, and silver sulfadiazine (Silvadene). Once the tissue granulates, the wound can simply be treated with wet to dry dressing changes; only in rare circumstances is a local or a free flap necessary.

Those favoring surgical treatment also point out the relatively uncomplicated nature of the procedure. There is no evidence showing that primary augmentation is more effective than simple end-to-end repair in acute tears. Therefore, more extensive procedures using tendon transfers, flaps, or mesh are best left for use with delayed tears, in which the repair will be under tension due to the chronically retracted ends.

Monday, February 4, 2008

You gonna tell me the difference between this guy and that guy is luck?

I am shocked the doctor has given me the okay to ditch the boot. I have been reading on the internet about many people’s experiences with this injury and they all appear to have different recovery times. Some orthopedic surgeons are conservative and some, like mine, are very aggressive. Every time I visit with my doctor I ask him, “When can I play basketball again?” Every time he gives me the same answer, “six months.”

Some people (who posted on http://www.achillestendonblog.com/) stated that they have reported not losing the boot until week 14 post operation! I am not using my boot at week 8 post operation. It appears every surgeon does things differently based upon their experiences. Every day my leg is getting stronger. The atrophy of my calf was bad, but I have noticed it is improving. When I first started walking without the boot, I walked with a severe limp. Now in just the past few days it has improved greatly. Although, the tendon still feels stiff. When I am walking I can feel the tightness of the tendon, almost like I haven’t stretched it in months (in which case I haven’t). I know I could not stand on my toes or walk up stairs if I wanted. As my limp dissipates, I cannot wait to see what I can do in a month from now.

Monday, January 14, 2008

Pop quiz, hotshot. What do you do?

Here is a general crash course of what you’re in for.

General Considerations:
- Time frames mentioned in this protocol should be considered approximate with actual progression based upon clinical presentation. Physician appointments as well as continued assessment by the treating practitioner should dictate progress.
- Avoid forceful active and passive range of motion of the Achilles for 10 - 12 weeks.
- Carefully monitor the tendon and incisions for mobility and signs of scar tissue formation. Regular soft tissue treatments (i.e. scar mobilization and friction massage) to decrease fibrosis.
- All exercises should be carefully observed for any signs of compensation or guarding.
- No running, jumping, or ballistic activities for 6 months.
- Aerobic and general conditioning throughout the rehabilitation process.
- M.D. appointments at Day 1, Day 8-10, 1 month, 2 months, 4 months, 6 months, and 1 year post-op.

0 - 3 weeks:
- Adjustable boot locked out at 30 of plantar flexion.
- Non-weightbearing for 3 weeks--no push off or toe-touch walking.
- Pain and edema control (i.e. cryotherapy, electric stim, soft tissue treatments).
- Toe curls, toe spreads, gentle foot movement in boot, straight leg raises, knee flexion/extension.
- Well-leg cycling, weight training, and swimming for cardiovascular conditioning.

3 - 8 weeks:
- Gradually increase weight bearing from toe-touchdown to partial as tolerated. After 6 weeks, okay to progress to full weightbearing.
- Walking orthosis adjusted 5 degrees a week until 10 degrees of plantar flexion. After 8 weeks, okay to wear shoes with a heel (i.e. cowboy boots, 1/4 " heel lift in shoes).
- Isometrics of uninvolved muscles, light active dorsiflexion of the ankle until gentle stretch of Achilles. Slowly increase the intensity and ranges of isometrics of Achilles within the range of the boot.
- Slowly increase passive range of motion and stretch on the Achilles after 6 weeks.
- Proprioception exercises, intrinsic muscle strengthening, PNF patterns (not to Achilles)
- At 6 weeks, okay to add stationary cycling with heel push only. Deep water workouts.
- Soft tissue treatments daily.

8 - 12 weeks:
- Full weightbearing with heel lift as tolerated, gait training.
- Wean into a regular shoe over a 2-4 week period.
- Begin and gradually increase active / resistive exercises of the Achilles (i.e. submaximal isometrics, cautious isotonics, Theraband)
- Manual full passive range of motion of the Achilles--nothing forceful.
- Progress to cycling in shoe, swimming.

3 - 6 months:
- Wean off heel lifts (if not already).
- Closed chain exercises: controlled squats, lunges, bilateral calf raise (progress to unilateral), toe raises, controlled slow eccentrics vs. body weight.
- Cycling, VersaClimber, rowing machine, Nordic Track (gradually).
- Unless excessive fibrosis present, should be discharged into a home program.

6 months - 9 months:
- Progress training jogging / running, jumping and eccentric loading exercises, noncompetitive sporting activities, sports-simulated exercises.
- Return to physically demanding sport and/or work.

Monday, January 7, 2008

Something caused all this. But what caused...that cause?

Causes of Achilles tendon rupture

Your Achilles tendon helps you point your foot downward, rise on your toes and push off your foot as you walk. You rely on it virtually every time you move your foot. Injuries to your Achilles tendon result from repeated stress on the tendon, which may be caused or aggravated by:

-Overuse
-Running on hills and hard surfaces
-Poor stretching habits
-Tight calf muscles
-Weak calf muscles
-Worn out or poor fitting shoes
-Flatfeet

Injuries to your Achilles tendon can often result from taking part in an activity involving stop-and-start footwork for which you're not conditioned or for which you haven't stretched properly. This might include playing tennis, racquetball or basketball for the first time after a long break.

Sometimes, though, injuries can occur from simply putting too much stress on your Achilles tendon in the course of a simple activity, such as gardening. Occasionally, even highly conditioned athletes may rupture an Achilles tendon.

As you age, the risk of Achilles tendon rupture may increase. If you don't exercise regularly, the Achilles tendon may weaken and become thin, making it more susceptible to injury.

An Incident!

This is how I ruptured my Achilles tendon. Feel free to share your stories. I was playing a pickup game of basketball at my local Lifetime Fitness. I had already played one game earlier and was starting my second game. I was on the left baseline of the court when my teammate gave me a give and go pass. Only when started to go it felt like Bruce Lee gave me a kick to the back of my left heel. I knew right away something was right. I have sprained my ankles plenty of times. This was not an ankle sprain. It was a bizarre feeling at first. My foot literally did not work. I would try to walk and my foot would not respond. Everyone told me there heard a loud pop, but I didn’t hear anything. After icing for about ten minutes I grabbed my stuff and limped home. It really did not hurt that much, and I can see why some people do not see their doctor as soon as possible. The next day I saw my primary physician, and he recommended me to an orthopedic surgeon. The surgeon game me the Thompson Test and stated I have ruptured my left Achilles tendon. I thought I would be given an MRI or something. Nope. Just a date for the surgery I was having next week.

I am 27 years old. I have been playing basketball for at least twice a week since high school. Thinking back upon it, I had a pain in my left calf in the earlier game. I have always had aches and pains playing basketball, but I should have stopped right then and there. Coulda, Woulda, Shoulda. At least it was not my right Achilles tendon. I feel sorry for the person that can’t drive around.

Another surgery. I recently had an emergency appendectomy earlier this year. Acute appendicitis is no fun. The difference with the Achilles tendon surgery is you have time to think about all the horrible things that can go wrong. The appendicitis happened so fast and I was in so much pain I wanted that bugger outta there.

I can into the out-patient surgery wing of the hospital at 7:15 A.M. My Surgery was schedule for 8:45 A.M. I was checked into a small room and changed into the gown they gave me. The nurse put in an I.V. The anesthesiologist came in to talk to me about the procedure. He asked a couple of questions about my prior surgery and how I did with the general anesthesia. I was asking him I bunch of questions but I could not understand him, I believe he was from Croatia. His accent was heavy. I told him I felt no ill effects before. He asked me if I wanted general anesthesia or a spinal shot. I elected to have general anesthesia. I didn’t have to wear a catheter. Hurray, No Catheter!

They rolled me into the pre-op room where I met with another nurse the Croatian anesthesiologist and another anesthesiologist and the surgeon. They told me they made a last minute decision to give me a nerve block. They inject a numbing agent into the nerve of my leg. It is done to help the patient with post op. pain. I rolled onto my stomach and could hear the Croatian explaining to the other anesthesiologist where to inject the needle into my nerve. And then…..Darkness.

Awake…I was in the post op. room on my back with a cast on my leg and a bag of ice underneath. The nurse said the operation only lasted 45 minutes. If this is going to your first time going under it is a trip. I couldn’t feel a thing in my left leg. I went to the bathroom, put on my clothes and went home.

Fast forward roughly 24 hours later when the nerve block wore off. Holy Christ was I in Pain. The pain hit in a matter of minutes. It was painful. It eventually wore off, and I was only on painkillers for a couple of days.

Just a side note they give you a lot of antibiotics to take after the surgery. The biggest problem post operation is an infection of the wound. At the time of writing this I am four weeks post op. and have had not problems.