Achilles Tendon Pain + 2 Surgeries: Still Painful

Hi Doctor Blake,

My name is John (name changed). I now live in Valley Springs California. I have been on the internet researching Achilles tendinitis/heel pain and found your blog.

 I have been having Achilles tendon/heel problems since July 2010. I have been dealing with another podiatrist. I was told in July 2010 I had a partial tear of my Achilles tendon and some real large bone spurs.

 Because I am a diabetic they did not want to do surgery at this time. I was placed in a cam walker, but the pain got worst and I was placed in a NWB short leg cast. I was in the cast until October 2010. The pain got better, but as soon as I started rehab, the pain returned.

 I was put back in the SLC walking cast until the 1st of November. At this time an MRI was done. The MRI showed the tear and the bone spurs. The podiatrist wanted me to go back into a cast. Being from the old school of sport medicine, I suggested a long leg cast to completely keep my heel from moving. The podiatrist finally agreed to my request. My foot was plantar flexed for the first 3 weeks, then the foot was raised about 10 degrees for another 3 weeks. The last 3 weeks my foot was at 90 degrees. After that I was put in a SLWC for the next two weeks. Finally I was put back in the cam walker. While in the long leg cast my heel felt much better, but when I when back into the cam walker and started rehab the pain returned just like nothing had been done.

 Finally in March 2011, the podiatrist decided to do surgery. She was to repair the tendon nd remove the spurs and scrape the heel smooth. She decided to use the Topaz procedure on the tendon. Everything felt good until I had my knee scoped to clean up a partial tear of the cartilage. Soon after the scope of the knee the Achilles tendon pain returned. By September 2011 the pain felt like I had just injury my heel. X-ray showed that bone spurs had returned.

 I changed podiatrist and had to start my treatment all over. He place my leg in a SLWC for the next 2 weeks. But it did not help. He suggested the long leg cast again. I was in it for 6 weeks. After that I was placed in a air cam walker. This lasted until April 2012 until a second surgery was done. Again the tendon was removed the spurs removed and the tendon reattached.

 In December 2012 I started a rehab program. Near the end of January 2013 the pain has returned. The podiatrist had earlier tried injecting the heel and putting it in a cast, but it did show any sign of improvement. The podiatrist had order ultrasound treatments but was over ruled.

 I worked for 25 years as an athletic trainer and started my own rehab program. The more I do the exercises the more painful it becomes. The podiatrist asked me to look into calf lengthening surgery. I have very high arches. The podiatrist now feel I have a very bad case of Achilles tendinitis. He feels that because I have very tight calf muscles lengthening the tendon might helps.

 What do you think about calf lengthening surgery?

 Or do you have any other suggestions for treating my Achilles tendinitis?

 What can you tell me about the Topaz procedure and it success or failure in Achilles Tendon repair?

Dr Blake's comment: Let me start out by saying that achilles tendons are very tricky to deal with. You simply look at an achilles the wrong way and it starts to hurt. And, every day you have pain in the achilles you lose up to 1% of your strength, so let us assume you have no strength in that achilles. The weaker and weaker the achilles gets, intensified by prolonged casting, by the time you had the second surgery your achilles is jello!!! And it will hurt if you use it. And you must get it strong again. Stay away from surgery if they are just guessing. If you lengthen the tendon, you will make it weaker. You know about force length curves!!!!  Your tendon must be so weak you can not even walk without straining it. Why was there no mention of tightness issue until now? 

     What do you think is going on now? Are the spurs finally gone? Is the tendon intact? Topaz is fine as a technique to repair, but did they do it correctly is a whole other question? But, if there was concerns, I hope they would have addressed that in the second surgery.

     Without further info, let us assume you have repaired the stuff you needed to have been repaired, and now you have a weak, tight, swollen, strained, fragile achilles on one side of your body and a strong healthy one on the other side. And you begin to rehab without more casts. You get orthotics that center your heel from a good orthotics guy/gal, you limit your activities to pain free as much as possible, you ice 5 to 10 minutes multiple times a day, you stretch and stretch and stretch (see my blog videos), and you find what strengthening you can do for the achilles that does not hurt, and you slowly get stronger, and stronger, and stronger over the next 12 months. 

     Since, no one bothered to look at the sciatic nerve as a possible cause or aggravating factor for you, definitely have a physiatrist look into this as one of your pain triggers. Why are people saying you hurt this much? Just tendinitis? 

     I hope this points you somehow in some direction that is good. I am sorry for your struggles. Rich Blake

Achilles Tendon Rupture and Body Pump Classes

Here is an email received on 3/21/11

Anonymous has left a new comment on your post "B.R.I.S.S. Principle of Tendinitis Treatment":

Hi,

I am a aerobic instructor (body pump, rpm and bodystep) and I have just had achilles tendon surgery (achilles tendon stretched over heel bone). It has been five weeks since my surgery, and I am now in a walking cast. I would like to know when it would be reasonable to go back to teaching. I realise I have months of physical theraphy ahead of me. Would it be possible to get back into teaching bodypump around 5 months post op?

Thank you very much for any advice.


For any of my readers unfamiliar with body pump, here is a short you tube video which is good to watch before reading my response.



     Thank you so very much for your email. Even though I do not do this surgery, I have rehabed patients successfully back from the surgery for many years. This answer can get more refined as I learn from your physical therapist the state of your tendon's flexibility and strength (this can be emailed). I will assume you were very strong before surgery in your calves, so we must use the noninjured side as our comparison. In the 1970s you assumed the injured side would only get to 90% of the normal side in strength, but in 2011, with all the improvements of therapy, 110% is common in an athlete like you. Yes, you will get the injured side to 110% in strength since you want this never to happen again.

     First of all, strength gains can not be obtained with Bad Pain. So, please become an expert on Good Pain vs Bad Pain and live in the Good Pain realm. See the link to my post on Good and Bad Pain and memorize it. It is the only way to say reasonably objective, along with your physical therapist's and surgeon's guidance.

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

     When I watched the video on Body Pump, I realize that your classes may be more intense. As an instructor, it would be hard not to demonstrate, but some level of cheating on technique will occur. You must assume with surgery that the calf/achilles have stopped working and you have little to no strength. You are starting all over. With this surgery, regaining strength is key. Tone comes first, then gradually power, and then finally endurance. Power and endurance come slowly unforunately and our key to preventing re-injury. Typically, even in well trained athletes, the endurance strength takes 12 months to get to that 110% level, but you will need only 50-60% strength to start teaching protected. On average following injury, you lose 3-5% of your overall strength daily until you painlessly begin to restrengthen. At 5 weeks post surgery, not injury, if you do the math, we can assume your achilles and calf are like jello. So, you need to begin to strengthen now, and as painlessly as possible. This is not the time for No Pain No Gain.

     As you strengthen the calf/achilles, you will gain tone first, power second, and endurance third. You unfortunately gain much slower than you lost. Tone is gained, as long as you do not push through pain, at 1% per day at best. So, given a good strenghtening program, in 2 monthes you will have 60 % of you tone back. That will give you some protection for your achilles, probably along with a tightly wrapped ASO Ankle Brace, and you can start going back to class. The problem is that tone is gained 1% daily, power at 1/3% daily, and endurance 1/4% daily. These are rough but good generalizations.

    I have found that 80% of normal power is acceptable at achieving initial athletic goals. This will occur 240 days from now, or approximataely  9 monthes from surgery. This is when the average patient after achilles surgery begins a running program (with the range from 6 to 12 monthes). For teaching Body Pump Classes initially you will not need 80%, probably only 50% since most demonstrations can be done with both feet on the ground (like squats and upper extremity strengthening). You should hit 50% at 150 days or 5 monthes after surgery!! See how the math works.

    The real problem is at 5 monthes will be the lunges and any other forced weight bearing exercises on predominately on one leg. When doing a lunge, the back foot is in a heel non weightbearing/ suspended position (thus unstable and prone for too much chance of injury). Please see my previous post on Negative Heel Stretching which you should not do for several years post surgery, and explains the precarious position of the off weighted heel.

http://www.drblakeshealingsole.com/2010/05/quick-tip-6achilles-stretch-to-avoid.html

     A good physical therapist, and many trainors, will be able to help you improving in tone, power, and endurance over the next year. 5 monthes is the normal time to start back when you are at 50% power for Body Pump, but higher levels will take 80-90% (and this will not be achieved for 8 monthes or 240 days). Endurance just takes time, and is associated with painfree sport specific exercise (for me, I just have to go out and play basketball and build up my strength). For ACL repairs, Tommy John Surgery, Achilles Tendon Repairs, and a few other surgeries, the 2nd year is really the Endurance Year. That is when you feel like your old self again. It takes 4 to 12 monthes working out at a high level to regain your endurance back. The second year normally begins with you just starting or up to 2 monthes into a high level of activity. So, be kind to yourself the second year. Until you get back your endurance, your fatigue level is lower than you want, and pushing through fatigue is when injuries occur.

     Read over my post on types of strengthening exercises (see Question #18) and then you will have better conversations with your PTs/Trainors on tone/power/endurance.

http://www.drblakeshealingsole.com/2011/01/biomechanics-3-sports-medicine-summary.html

     I want to close with two points.  #1 strengthening above the calve is vital to building good strength back for athletic endeavors--quads, hams, core, esp. There is an indirect but powerful protective mechanism in strengthening above the injury. I believe it really pays huge dividends when you are in the endurance phase. And #2 see the post on the Power of 2 postitional toe raises. Once you are doing 2 sets of 25 one legged toe raises daily with ease you are at 80 % power. 1 set of 25 is around 50% power and when you are ready to start teaching Body Pump. I sure hope this helps.

http://www.drblakeshealingsole.com/2010/10/achilles-tendon-strengthening-video-on.html