Is it May yet? Peroneal tendon rupture, surgery, and rehab, part 1

Opening up my blog to start this post made me notice that my last post was about a medical problem.  I guess this is fairly appropriate--my year was largely a sequence of lurching from one problem to the next, with a few nice runs and climbs in between.  If things don't improve soon, I'll rename the blog something like aliciasrestingandrehabilitationwoes.

The closest I'll get to running Zegama this year

At the end of a great long run in the mountains, I was running down a moderately technical descent when I landed badly and injured my foot.  I heard a loud cracking noise so was fairly sure there was a broken bone.  I limped off the hill, hitchhiked back to my car, and drove straight to the hospital.  This was the start of a cascade of comedy errors that leads to my current situation.

The emergency room doctor took an x-ray and reported that I had a broken 5th metatarsal.  She thought it was a Jones fracture and thus might need surgery, so she told me to see a specialist.  This was incorrect--it was a fracture to the base of the metatarsal and not a Jones fracture--but her mistake turned out to be lucky for me.  The surgeon who I went to see about the fracture was able to tell immediately that it wouldn't need surgery, but fortunately for me, he noticed that I seemed to be missing my peroneus brevis tendon.  After multiple errors with the MRIs and an inexplicable order for a second x-ray, and thus plenty of delay, it was determined that I had a complete rupture of the peroneus brevis at the point where it inserts into the 5th metatarsal.

This could only be fixed with surgery, but there were an endless number of delays to getting a surgery date, and I finally went for the operation 7 weeks later.  By that point the metatarsal fracture seemed to be healed and I had been able to walk a little, but I had been on crutches 95% of the previous 7 weeks.  That meant my peroneus brevis stump had had 7 weeks to retract and atrophy.  Sure enough, my surgeon reported after the surgery that there was hardly any of it left.

What he didn't report was that he had done an entirely different repair technique than what it appeared he had been planning.  I learned from my hospital discharge form that what he did was tenodesis--sewing the peroneus brevis stump to the peroneus longus tendon--whereas I was under the impression he would be doing an allograft (cadaver tendon) repair.  It appears that this type of tenodesis is a common way of dealing with a lack of intact tendon to work with, so I can see why he would have done that.  However, I had made it abundantly clear to him that I was a competitive runner, that I ran in the mountains and needed maximum ankle stability, and that my priority was getting back to this.  Tenodesis is not at all ideal for any of these things (I believe you can read a good article about different repair options here without a paywall, http://www.foot.theclinics.com/article/S1083-7515(13)00104-6/pdf) so I was not particularly pleased, to say the least.  If my surgeon had been experienced at treating athletes, I could feel confident that he had correctly weighed the pros and cons of each option in deciding what to do.  However, it was clear from our pre-surgery conversation that he had little experience with athletes.  At the time, I thought this was okay because there was no question of what needed to be done; all I really needed was an experienced surgeon who could do the repair well.  It simply never occurred to me that this particular type of problem ("two tendons enter, one tendon leave"...?) might occur.  It was also clear from pre-surgery appointments that my surgeon was very interested in seeing the maximum number of patients possible, and this does suggest he may have chosen tenodesis on the basis that it's a much simpler and thus quicker procedure.

Frankenfoot, about 5 days post-op

After the surgery, I wasn't about to waste my time and money on more rushed, interrupted appointments with my surgeon (his appointments are 3 minutes long and mostly involve him talking to his assistants), so I took advantage of a friend's student status and downloaded all the relevant rehab articles listed in this review, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823352/.  It immediately became clear that there is a vast range of opinions from surgeons on the appropriate rehab program for this surgery.  Everything from immediate weight bearing to 8 weeks in a cast was on the table!  I went with a protocol that fell in the middle of the options, which was:

--2 weeks in hard splint
--Staples out at 2 weeks
       --If you're having this surgery done:  ask for stitches rather than staples!!  I would say as much
         as 50% of my pain in those first two weeks was from the lovely feeling that is 26 bits of metal
        digging into the area around a recent stab wound.
--Dorsiflexion/plantar flexion stretching exercises starting at 2 weeks
--Partial weight bearing in a walker boot from 2.5 weeks, starting VERY lightly with just a few toes on the floor and progressing extremely gradually as tolerated
--Full weight bearing when tolerated
--Standard physical therapy range of motion and strengthening exercises starting from 6 weeks
--Running on an alter-G treadmill
--Back to regular running no earlier than 12 weeks but potentially more like 14-16
--Plenty of sleep
--Lots of protein and very little sugar (high glucose diet seems to impair tendon healing in rats, and it certainly won't hurt to try!  https://www.salk.at/DMS/41598_2017_Article_700_1920815.pdf)
--Restricted eating window and coconut oil to encourage BHB production, which may have an anti-inflammatory effect:  https://www.ncbi.nlm.nih.gov/pubmed/25686106/.  My hypothesis was that this would give me the benefits of a ketogenic diet without the increase in cortisol I would get if I actually went on a ketogenic diet.

This all went reasonably well for the first 5 weeks, with plenty of bad days mixed in but overall it was a steady upward trend.  I did have a deviation from the plan though:  my walker boot, which I had been using for the metatarsal fracture, was very painful for the newly-repaired tendon.  I experimented a bit and found that a compression sock + ankle brace + wide-foot running shoe + running insole actually felt much better and more stable than the boot, so I switched to that early in week 3.  This may or may not have been a mistake...

By early in week 4 I was walking with two crutches and with about 50% of normal weight on my injured foot.  Later in week 4 I progressed to walking with one crutch and felt strong enough to try a few steps unaided.  They felt fine, and I did maybe 20 steps in intervals of 5 at a time, although the next day my foot was quite sore so I went back to two crutches and tried to generally stay off my foot.

Then things took a turn for the worse.  Divesh and I were headed to India for a week, and my foot was not pleased with two days of crutching around airports and the long flight time.  When we got to India, I took a day completely off any weight-bearing.  On the second day, I went back to walking with two crutches--and it did not go well at all.  My foot developed a raw, stabbing pain that evening and it was so painful that I couldn't sleep through it.  The next day was about the same.  It eventually calmed down to a more manageable pain level, but something is clearly different than it was during the first 5 weeks.

And that is why this is only part 1...I'm currently booked in to see a different surgeon, one who has just had an impressive result with my runner friend Diana's complex ankle repair surgery, in a few days to discuss my options for where to go from here.  I'm interested to hear whether he thinks it's possible and/or worthwhile to reverse the tenodesis and repair with an autograft or allograft instead (so far I've had conflicting information on whether or not this is possible; a 2014 case report says it was done but a very experienced surgeon in this area discussed it with me via email and said he doesn't think it can be done).  I'm also obviously keen to hear what he thinks may have happened to the current repair and whether or not there's any way of determining in the near future if the repair failed.

For now I've bought a different style of walker boot and I'm back to almost zero weight bearing.  I'll write part 2 when I've got an idea of where I go from here!