Ankle Outcomes Part II: Getting Physical

Posted by on March 27, 2013 at 10:05 pm :: 3 Comments

When I went to see my surgeon in November to discuss my most recent ankle drama, he gave me a prescription for physical therapy. I opted to wait until after Christmas to start those early morning sessions with my physical therapist because I knew my treatment would not be over quickly. Although it took three months of intensive work before I graduated to just doing exercises on my own at home, all the aches and early risings were worth it. My physical therapist brought my foot back from the brink of uselessness. Here are all the details of my rehabilitation that will keenly interest my ankle buddies but completely bore everyone else.

One of the first things my physical therapist told me on my initial visit was that both of my ankles are very strong. The balance on my left ankle, my bad ankle, was surprisingly better than my right, according to preliminary tests, but the mobility on my left was impaired. (Subsequent tests showed that leftie was inferior to righty in balance as well so I’m not sure how it fooled the system at first.) My PT worked me good that morning and made me a bit sore but a couple of days later I was back for more.

Over my next couple visits, my therapist started making things harder for me. Apparently, with tendinosis you have to drive the tendon a little crazy to get it to heal. Tendinitis requires delicacy but tendinosis needs toughness. In tendinosis, the tendon is in bad condition and the tissue isn’t regular. Usually, a lot of scar tissue is present. Scar tissue contains significant quantities of type III collagen instead of type I, which is what a healthy tendon is primarily comprised of. A tendon in this deteriorated state has to be encouraged to rebuild itself in a better, more normal, way. That encouragement, unfortunately, must come in the form of aggressive insults. Tendinitis is much easier to deal with than tendinosis but you know me, I don’t like taking the easy road.

What determines if a tendon injury will result in tendinosis or tendinitis? Here’s what my PT said: The condition of the tissue before the injury is important. My ankle already had scarring prior to this latest incident so please put a check in the tendinosis box for me. The severity of the injury is also a factor, the more severe the damage the more likely tendinosis will occur. My sprain was bad news so, once again, it looks like I was destined for tendinosis. And lastly, how much the foot is allowed to rest and mend after it’s wounded also plays a part in how the tendon reacts. If you try to do too much too quickly then you are asking for tendinosis. Before you start pointing an accusatory finger at me on this account, you should know that, despite my usual tendencies, I was pretty good about letting my ankle heal this time. I say “pretty good” because I may not have given it quite as much pampering as most would have but I gave it significantly less grief than most Rachels would have. My previous experiences with this particular foot convinced me that it was probably unwise to hike to the top of a towering peak the day after I rolled it. (And yes, that is exactly what I did the first time I tore my tendon but didn’t realize it.)

I bought a BOSU ball so it would be easier for me to do my therapy exercises at home.

I bought a BOSU ball so it would be easier for me to do my therapy exercises at home.

At this point, I could tell that physical therapy was pushing my foot to aggravation. Doing my “homework” caused stiffness and pain and so did my visits to the PT. But apparently, since pushing is the purpose of this therapy, everything was going according to plan. In fact, my physical therapist gently told me to get used to the agony because he was just going to keep making things tougher on my ankle with each visit. Fantastic.

Before my next PT appointment, I went snowboarding for the first time since my sprain. Snowboarding hurt but it hurt in a way that I wasn’t expecting. The pain was in a different place than it used to be before surgery. The discomfort was more in front of my ankle bone than below and it was so severe that I almost called it quits early on the mountain, which is not normal for me in any way. When I explained where the painful spot was to my PT, he was certain right away that it was my sinus tarsi. The sinus tarsi is a small cavity that contains ligaments and joint capsules. It’s a crowded area where a lot of things intersect. My issues in that region, he believed, were a result of a buildup of scar tissue, AKA fibrosis. Scar tissue creates stickiness and impedes the motion of connective tissues. In the sinus tarsi, which is packed tightly anyway, a little fibrosis can create quite a bit of friction. This, for obvious reasons, doesn’t feel good but it’s common after a serious ankle sprain like mine.

My next few trips to the PT passed with nothing new to report: more exercises and more discomfort were the name of the game. Finally, after a number of meetings, I felt the time had come to ask my PT a question I was almost afraid to have answered: Is my foot in good enough shape to participate in a half marathon at the end of April? His response? Probably. He gave me permission to begin training for this event but he cautioned me to only increase my running distance by 10% each week. He also warned that if my ankle starts swelling or becomes persistently painful for more than a couple of days after running then I’m overdoing it and I need to back off. Let pain be my guide, he suggested…maybe not the best advice for someone as stubbornly and irrationally prone to ignore aches as me.

On my next visit I progressed to the hardest exercise stage, known unfancifully as level 3. Those advanced exercises didn’t go over so well with my foot, especially the side-to-side jumps. My ankle would hurt for hours afterward and swell in an odd fashion. It would bulge at the sinus tarsi, which is where I expected problems, but also up closer to my toes in a strange little bubble and in an area beneath the backside of my ankle bone. My PT said that all of this puffiness was probably due to just my sinus tarsi swelling. Apparently, with inflamed tissues, bits of fluid break off and get lodged in random places like that. Well, I’ll be a monkey’s uncle. My PT wasn’t pleased with how my ankle was handling my advancement to level 3. Evidentially, therapy exercises shouldn’t cause pain for more than a couple of hours; even therapists have their sadistic limits. I was put back on a routine in between level 2 and 3. My PT also recommended that I give my sinus tarsi a mean rub every day to help break up the scar tissue that was causing me so much grief. And I do mean mean!

As my number of PT visits was getting into the double digits, my therapist informed me that I needed to do my home exercises for six more weeks but I was almost done coming to his office. After another three or four weeks he said I should try doing the advanced exercises again, the ones that my ankle had previously rejected, every other day to see if it would handle them okay. He also said that it’s entirely possible that my ankle will never be able to do those types of activities without hurting but, since they are specialized movements, I probably won’t notice any issues while performing my day to day activities. Despite his reassurances that, either way, I won’t have many restrictions on what I can do, I wasn’t happy with the idea of permanent limitations. “You may never be able to do that.” is a phrase that just doesn’t coincide with Rachel ideology.

In my last full hour appointment with my PT, he told me that my ankle should keep improving in stability and mobility over the next two or three months and then it will be about as good as it’s going to get. He tested my foot on his fancy machine and, at that point, my medial/lateral stability (side-to-side) on my left ankle (AKA baddie) was within the normal range but it wasn’t as good as my right, which had better than normal stability. My front-to-back stability was about the same on both my ankles.

During our final chats that morning, my PT said that as long as I’m not snowboarding every other day then it’s okay if I hurt on the slopes. This was not a callous comment but a professional observation. His meaning was that just because I’m in pain doesn’t mean that I’m damaging myself. I guess it’s comforting to know that I won’t be hurting my ankle even if it’s hurting me. With my therapist’s approval to go ahead and suffer, my sneaky ankle must have realized the futility of grumbling about my favorite winter pastime. When I went boarding in mid-February it behaved much better than it had a month earlier at Powder Mountain. It didn’t throb much while I was on the slopes. However, upon doing my therapy exercises the next day, it became very shaky and remained achy for over 24 hours. What the what ankle? Why must you mar my victories with your drama queen tendencies!

On my follow-up visit three weeks later, my PT tested my ankle’s stability once again. Drum roll please! It had improved drastically in those three weeks. Yes, I had been doing my homework; I am a teacher’s pet after all. The medial/lateral stability on my left ankle was still not as good as my right but that gap had been narrowed substantially. Both my ankles have better stability than normal now. No, you wouldn’t want to go head to head with these feet because they are mean, not green, stable machines.

At that meeting, I spoke with my PT about how my half marathon training was going…or resisting going. My ankle had started giving me grief as soon as I increased the length of my runs past what it was used to. My therapist said that this was to be expected given the degree of scarring in my foot. He recommended that I ice my foot after each run. He also suggested that I not do my home exercises on running days.

Somewhere in this discussion, the subject of my odd gait came up. My PT found it professionally quite interesting that I run/walk on the outside of my feet. This strange habit was partly blamed for my first tendon fiasco and, according to my PT, is quite uncommon. Walking on the inside of the foot is the normal way most people step incorrectly. I guess I’m weird. No, don’t bother telling me that you already knew that.

And that concludes the intriguing tell of my ankle’s diagnosis and recovery. I am still in the process of training for my halfy, in fact my foot is on post-run ice at this very moment. So far that training has been going as well as I’d hoped, which is to say not spectacular but not awful. I’m still moving onward and upward though with my most troublesome of appendages. I’ll be sure to keep everyone updated on the exciting life of lefty in future yawner posts.

By the way, if anyone that lives in these parts needs a physical therapist, I’d highly recommend mine. He is very competent and made the miserableness as pleasant as possible. Just holler and I’ll be happy to pass his name along.

3 Comments

  • jd says:

    Hey, been reading about peroneal tendonosis and I got it back in the end of March of this year. They said no tears and rehabed till Sept and started running again but it takes forever to break up all that scar tissue. I am wondering how your ankle is holding up. I had two MRI’s, they said no tears but as you stated the MRI’s can show tendonosis but be worse overall which is what I heard to. Did your MRI show a tear. Anyhey, just thought I would post and see how the rehab was going?

  • Rachel says:

    Hi JD,

    The awful sprain that lead to my tendonosis was the second major injury that poor ankle had suffered. The first injury was a tear in my peroneal tendon that was misdiagnosed and had gotten to the point of nearly rupturing before it was fixed via surgery seven years after I had torn it. Based off my experience with MRIs, they are definitely not infallible. With that tendon tear, the MRI only showed some minor lesions, nothing worth getting surgery over. And yet, it was actually almost torn past the point of being repairable.

    The MRI of my later ankle sprain did also show some minor tearing of the tendon but I believe these results were accurate. My ankle feels much better now. It will never be what righty is but, with all it’s gone through, that’s to be expected. However, I am able to do any physical activity with it these days, though I do still use my ankle brace occasionally.

    I hope your ankle continues to heal. If time and physical therapy don’t improve it, it’s possible your MRIs weren’t accurate. Don’t wait seven years to reconsider the issue like I did and end up with an almost-ruptured tendon. 🙂

  • jd says:

    Thanks for replying, yea, I had been running trails for years got up to 50mpw and started to push it a little to much this past march. On a 7 mile run, I rolled it twice but it didn’t swell so I figured I was ok. Rest for a week, then back at it but it didn’t feel that good. About a month or two go by and I get a MRI and it says no tears but I have moderate peroneal tendonosis. 2-3 more months of rehab go by and still not feeling better, got another MRI and it says *still* no tears and *still* advanced tendonosis. Now, its October and I began running in Sept starting by walking, then running a mile, then 2, now up to 20 a week. Ankle has a decent amount of scar tissue and my peroneal muscles are extremely tight. I have seen 20 doctors, just kidding but it felt like that and finally ended up with one who said I am not a candidate for surgery yet. He took the strenght of my ankle as a good sign as well as no swelling. Like your ankle, it is very strong but aches when I up the mileage. Got some rehab left but ran 4 miles today and it felt fine but still tight and a little achy. If I can’t get back to my normal self by jan, I might consider surgery. I had to cancel a few 50 milers and a 100 miler I was going to run this month. Hopefully, next year will be an injury free year.

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