Achilles Tendon Rupture - surgery repair with Xenograft

If you had surgery to repair your Achilles Tendon Rupture and want a fast rehab, click here to see the AAOS only 2 highest agreements to be in support of early (≤ 2 weeks) post-operative protected weight bearing and the use of a protective device that allows mobilization by 2- 4 weeks post operatively.


On December 4, 2011 I finished a 90 minute bike ride and then met up with some friends to play fag football at the local park.  We tossed the pigskin for another 90 minutes and I was feeling great but my calves and sprinting muscles were a little surprised to be doing all those short burst efforts (I haven't played a field sport in years).  With a normal acceleration to provide pass coverage on Ronimal Shevock, I heard a loud pop and instantly collapsed.  I thought somebody had stepped on my leg or kicked me, but really my Achilles tendon had completely ruptured.  Spontaneous combustion, no warning, no impact, no contact, etc.  A doctor friend came to the field to check me out and confirmed the tendon had snapped.  It did not roll up my calf and create a large ball; it didn't really hurt that bad either.  I was not able to walk, nor did I try to...

That night I confirmed the diagnosis with my own Simmonds-Thompson test by laying face down on my bed.  Here is a picture of the ruptured Achilles tendon (left foot).  You can see how the foot hangs at a different angle and there is no definition around the tendon:

Since the injury occurred on a Sunday, I couldn't get seen by a specialist until I made an appointment with my Primary Care Family Physician on Monday.  Luckily I got both of those appointments taken care of and by Tuesday we were waiting for insurance approval to perform surgery with xenograft on Wednesday (3 days later).

The surgeon, Dr Cedric Wong said the operation went well and he did use the pig's intestine (xenograft jacket).

The first day or two after surgery was quite easy because of the heavy medication.  They must put a block in your leg because the first day was very painless.  I did not continue to take the Norco prescription after the 2nd day so I was fairly uncomfortable until Monday (5 days later) when I went back to work at my desk job.  Sitting in the La-Z-Boy and watching TV for six days straight makes me bonkers.

I used a Knee Walker to transport myself instead of crutches. The walker is more like a knee scooter and allows you to carry things and open doors which is impossible with crutches.  Its sort of fun to ride I guess, which helps for an active person like myself.  Crutches are the worst, they should be outlawed.

After about 12 days I unwrapped the ace bandage and plaster half cast to take a sneak peak at the incision.  It is about 4-5 inches long on the inside of my leg, not straight up the back as expected.  I used a great product for taking a shower with the cast on, nice thick plastic bag with a heavy duty rubber collar.

At my 2 week follow up appointment the doctor gave me an air cast which can be removed for bathing and dressing.  My doc instructed me not to walk or do any weight bearing activities for 4 more weeks (6 weeks since surgery).  However there is quite a bit of research that says supported weight bearing and movement can occur at 2 weeks post op.

At 3 weeks you can see the improvement in the incision.  Its amazing how well the skin can heal an open wound. 

However, what isn't as exciting is the muscle atrophy of my calf...

5 weeks post-op I am now bearing weight in my air cast with a heel wedge and doing range of motion (ROM) exercises despite my doctors orders of immobility up to 6 weeks.  My tendon feels good, just tight in dorsiflexion so I don't push that much.  My day to day life is very sedentary.  I have a desk job and a nice family to take care of me at (our single story) home.  There is slight risk of re-rupture with early mobility but that would probably be a result of a fall or blatant behavior (bar fight:).   The other large risk with early mobility is gapping or tendon stretching.  

6 weeks post-op my ortho doc told me to continue the same path for 6 more weeks: Air cast full weight bearing, no weight bearing ROM.  That doesn't sound like my cup of tea so I am going to find some agressive rehab PT.  I cant let my leg sit in a cast for 3 months.  Obviously I am not going to ignore that I am injured but I also believe in aggressive rehab. Hopefully this mentality goes well for me! 

7 weeks post op, I am working out at the gym with the air cast on at least twice a week.   I do core exercises, upper body weights, stationary bike (10-15 min), and quad work.  I wear 2 shoes with heel insert around the office and the house and my air cast if I am going out and about.  My ROM is good and I've been pushing (gently) on dorsalflexion (the only direction thats limited).  I am going to start driving stick and using the clutch (injured foot plantarflexion).

8 weeks post op - I have completely stopped wearing the air cast.  Doc wanted me to stay with it for 12 weeks.  Keep in mind I have a desk job and a quiet life (right now).  If I were active on my feet and at risk of slipping, falling, etc then wearing the cast for another month would make sense.  Instead, I am using this time to gain flexibility, ROM, and strength in my injured leg.  

• Driving a standard transmission with clutch is going well; feels like a nice therapy at every shift.  
• I also quit wearing the heel lift shims.  
• Physical therapy prescription is just ultra-sound, weak massage and some gentle stretching.  The best treatment I have found is using the pool.  In the pool, I use the kick-board for some laps, then do egg-beater tread water for a minute or two, then I walk through the water at chest level to really stretch the dorsiflexion with less body weight.
• I am also using the eliptical trainer and 1 hour on the bicycle outside once a week.

10 weeks post op - I am pleased with my self prescribed aggressive rehab.  I go to the gym 4 days a week.   I am also doing about 1 hour on my road bike 2-3 days a week.  Riding hurts quite a bit and I cant go very fast or very far.  I mostly sit and spin, but can do a tiny bit out of the saddle.  I am trying to shake the limp in my walk, hope to be done with that by 12 weeks.  Some doctor friends have advised me not to worry about pushing that very much because it is the eccentric contraction: the motion that broke the tendon to begin with.  Pushing off from dorsilflexion.  General dorsiflexion is quite good, but still not 100%.  I can touch my knee to the wall when my toes are 4" from the wall.

you can really see and feel my Xenograft jacket (pig's intestine)

11 weeks - I suffered a pretty significant set back from overuse or too much aggressive home made PT.  With no significant single event, the top of my tendon/graft/repair began to swell and become irritated over the course of several days.  It was swollen, hot, bruised, painful and clearly not progressing or healing.  It could be the actual original rupture location.  I don't know if it was damaged with overuse, is healing long, or simply reacting to over use too early.  I actually had a very sick feeling while I spent at least a full week very concerned that I had done permanent damage to the repair.

12 weeks - at my 3 month post op appointment my surgeon said he is concerned there may be permanent damage from too much activity.  He even told me to stay in the air cast for 4 more weeks to bring the total immobilized time to 16 weeks.  I wore the air cast again from weeks 12-13 and I have stopped all activity and followed very strict RICE (rest, ice, compression, elevation) program.  I no longer go to the gym or PT appointments.  All that being said, I think I am par for the course.  I refuse to wear a cast for 4 months.

13 weeks - the swelling has finally come down and the pain has subsided.  I have scheduled a new massage therapy appointment in a few days.  Hopefully we can break up the scar tissue and move toward some positive progress again.  The massage therapist thought it seemed long and oddly shaped.  She didn't seem impressed and said, "poor you" :)   I have a appointment with a new and hopefully better PT in the morning.

14 weeks post op - I am finally back on track.  I basically had 2 week setback from weeks 11-13 by not following a good PT program.  The problem stemmed from my conservative surgeon who ordered me to stay in the air cast for 16 weeks and only prescribed ultrasound therapy for PT.  I knew that wasn't right for me so I didn't listen or follow the doctor's orders.  As a result I pushed too hard without making a solid foundation of basic rehab first.  Luckily I sought out the answers by seeking more PT appointments, paid for out of pocket.  Jeff Mitchell has been my friend and neighbor for a while, but I didn't know he was a PT.  Luckily my wife remembered that and I went to see him at home last weekend.  I also saw Paul Newton last week.  Both of them showed me how to do proper rehab for this stage in the ATR recovery process.  So now I finally feel that I am back on track.  Here is what I am doing daily now:

• 2 footed calf raises - 25 reps, 3x daily
• 15 min stationary bike spin - 2x weekly
• 1 footed balance - 3x daily
• calf stretches - 10x daily
• RICE - 10x daily

16 weeks - started dirt bike moto riding with an exterior cast.

18 weeks - dived back into bike riding with a group ride tues night, casual pace MTB wed night race, and 60 mile weekend tour called Party Pardee.  That was all too much activity and the Achilles is all puffed up and sore.

20 weeks - went to Las Vegas for a 3 day convention with lots of walking and standing.  Very stiff and swollen and sore.

6 MONTHS - not much progress, the tendon is still very large and stiff. Getting up in the morning is a limp to the bathroom.  Doesn't take too long to walk normal though.  Range of motion is equal to healthy foot, and my cycling power is starting to come around.  I have completely lost any definition from the soleus muscle in my lower calf.  Only time will tell if this is a permanent injury to my long term "performance output".

8 MONTHS - I finally feel healed.  Not 100% but I'd say 80-90%.  I have gone for 2 jogs and several demanding bike rides that rival my past competition training.  There is some burning and pain when the intensity goes up but I try not to worry (or do anything stupid).  The size and scar tissue has not reduced.