I tore my Achilles…now what?

It’s been 8 weeks since I ruptured my Achilles tendon. 7 weeks since I had it surgically repaired. They say experience is the best teacher and while I never hoped to have this experience, I’ve found that to be quite true. Here I’ll discuss some considerations around undergoing surgery and immediately after surgery. Primarily I’m going to focus on some of the ways I attempted to reduce downside (mitigate risk) to improve my chance of a successful outcome.

Firstly, if you’ve just torn your Achilles, you should understand that you don’t necessarily need surgery. There are protocols out there involving an initial immobilization period to allow the torn ends of the tendon to scar together and heal. If your tendon is not fully torn or demonstrates minimal retraction (separation of the torn ends) then you may be successful with this non-operative approach. If you want to avoid the risks associated with surgery (nerve injury, infection, blood clot, etc) you may choose this approach. However, if you’re young, healthy, active and intend to get back to running, jumping, pushing off your leg with a decent amount of force, the literature is showing that a surgical approach may be better for your circumstance, as the integrity of the tendon will likely be stronger with surgery.

You might be wondering why your tendon ruptured… fair question. Nobody can predict tendon rupture (or other injury for that matter). But it is clear that ~90% of individuals who rupture had a degenerative tendon to begin with. This is usually termed: tendinopathy. Unfortunately, tendinopathies can be asymptomatic, you might never know you have this until it’s too late. There are ways to reduce your risk of tendinopathy, but this will be for another post. Unfortunately, as we age our tendons become more collagenous and less elastic due to a reduction in fluid/gel within the tendon, resulting in a relatively stiffer tendon structure. Though if we continue to exercise and manage exercise volume and load appropriately and keep our tendons strong and healthy, we should still be able to participate in athletic endeavors.

Here are 3 components I focused on to minimize my risk and accelerate healing with my surgical repair:

1. Surgical complication: One of my major concerns was surgical complication; specifically nerve injury and infection. Unfortunately, these are both common with Achilles repair. The best way to reduce risk of nerve injury with a surgical repair is to choose a surgeon who uses a surgical approach that allows for visualization of the sural nerve of the lower leg (this is the most commonly injured nerve in this scenario). My surgeon used a mini-open technique. Not quite as invasive as an open technique but not as risky as an arthroscopic approach. This technique also allows for stronger sutures at the repair site, compared to arthroscopic. The mini-open also will have a smaller incision compared to a full open approach which should reduce infection risk. Once able to clean the incision after surgery it’s important to perform frequent sterile dressing changes. The surgeon/PA should guide you on how to do this. In thinking about infection, I wanted the incision to heal as quickly as possible, to reduce the duration of my potential exposure to bacteria. To accelerate this, I used a red light 20 min per day on the skin. In order for this to be potentially effective the wavelength should be ~630-700nm. There’s plenty of garbage red lights out there, so I tried to find a trustworthy company (mine is from gembared).

   
   

2. Avoiding over-elongation of the tendon: after the Achilles is surgically repaired, the foot and ankle are typically put in a cast for multiple weeks to maintain the ankle in plantarflexion (toes pointing downward). This is to allow the tendon to start healing without putting tension on the repair site. Basically this keeps the tendon shortened, then over the following weeks, the degree of plantarflexion is lessened and the ankle is gradually permitted to move back toward a more neutral position. This is a critical time for the tendon and the progression of ankle motion should NOT be rushed. It’s important to avoid stretching the tendon for multiple weeks (see surgical protocol for specific duration) to prevent excessive elongation. If the tendon becomes too long or stretched out, it’s unlikely to be able to transmit force adequately in the long term. A normal Achilles tendon has a 90 degree twist in it from top to bottom, which allows it function like a coil ( loading and unloading like a spring would). After a rupture, this twist is lost and cannot be fixed during surgery (at this time). The loss of this twist will contribute to a lack of force production ability to some degree, but if the tendon is over lengthened (stretched) too early in the healing process then a lack of force production ability is almost guaranteed for activities like running, jumping etc. A slow progression of range of motion is a test of patience for anyone who is active and eager to get moving again, but tendon remodeling takes weeks to months so it doesn’t need to be, and should not be rushed.

   
   

3. Nutrition: while load management is probably the most critical aspect of a safe and efficient recovery, nutrition should not be neglected. I focused on 3 main objectives with my eating; adequate protein/caloric intake, increased anti-oxidant intake, avoiding alcohol/spikes in blood glucose.

   Protein is critical for wound healing, among other bodily processes. From what I’ve read, we need at least 1.5g per kg bodyweight to optimize wound healing. For me that’s about 135g per day. I’m normally a bit obsessive about the food I eat, the sourcing, the quality of it. I grow a lot of my own food and love to forage and spearfish when able. Anyhow, I’ve focused on consuming a variety of protein sources including: eggs (pasture raised or local when able), yogurt (homemade Greek yogurt), fish/shellfish, nuts, seeds, tofu/tempeh, and multiple smoothies per day with branched chain amino acids (BCAA’s), pea protein, peanut butter protein, marine collagen (all from NorCal organics as they are grown in Canada and not processed in China like most proteins).

   Anti-oxidants have been shown to be relevant with tendon healing, and reducing inflammation. In my research I found support for a variety of anti-oxidants including: vitamin C (orange juice works, also helps with ability to absorb dietary collagen) high quality olive oil (looking for recent harvest, high polyphenol level, organic, first cold press), spirulina, goji berry, cinnamon/clove, turmeric, pomegranate, tart cherry juice and other red/blue berries.

   As much as I love a good locally-brewed Pilsner…I really wanted to maximize my healing capacity, maintain good sleep quality and minimize oxidation, so I decided it best to cut out any alcohol from my diet. Additionally, alcohol consumption can mess with blood glucose levels which can negatively impact tendon structure and healing. You only get one shot at healing your surgical repair, so might as well stack the deck in your favor.

At the end of this whole experience I fully intend to get back to surfing, climbing, spearfishing, mountain biking, hiking, running. These things help me experience a life worth living. If you’ve torn your Achilles or are trying to manage Achilles tendinopathy I’d love to guide you through the rehab process as well, please feel free to email me at Chris@explore-pt.com to chat