Peroneal tendon surgery part 3: the end?

I keep waiting for some sort of obvious "finish line" to signify that it's time to write a final wrap-up of the outcome of my injury and surgery.  But since I don't have a good idea of what that finish line would look like--running a race?  not thinking about how much my foot hurts every time I walk anywhere?--I decided that the triple achievement this week of wearing normal running shoes instead of hiking boots for a run, finishing a hard race, and filling out a weekly training log that wouldn't be too out of place in my pre-injury training would be good enough.

Sometime in June I got completely fed up with my situation and was saying to a friend that it had gotten to the point where it felt like I would never get back to normal running.  He replied with the excellent point that it might well not ever go back to normal, but that it might not be better or worse, just different.  And this is exactly what I've found.  Unless I get a revision surgery (more on that below), my ankle is always going to be weak.  This is just what happens when you're missing a major ankle tendon--you can only train the surrounding muscles so much, and you can't train something that's not there.  I may never be fast on technical ground.  I may have to wear my heavy, uncomfortable hiking boots in races for the foreseeable future.  I may be even more pathetic than I was pre-injury on steep downhills, even though my pre-injury standard is a standard that's difficult to fall below!

But...I may have been forced into a decision about what types of races to focus on, which might make me faster in those races eventually.  Since I can't run downhill very well yet, I've started running some uphill vertical races, which I'm not totally sold on yet but may grow into liking.  I am becoming more efficient about making my mileage count, because I can only do a fairly limited amount of miles.  And possibly most importantly, I discovered that there's nothing like being unable to run for six months to teach you exactly what kind of running you missed the most, which is very useful for deciding what type of running to do when you are finally able again!

So, it's different.  If I could choose, I would opt to have not lost a foot tendon, along with vast sums of money spent on medical care, not to mention six months of my life.  And it certainly grates on my mental well-being every time I think about how the outcome could have been improved had I not picked such a lazy and/or money-hungry surgeon.  But given that this is the situation that exists, it's not all bad by any means, just different. 

It's not yet clear whether this is the end of the saga or not.  When I saw surgeon #2 in March, he was somewhat appalled at what surgeon #1 did ("Why did he do that?!" was the exact reaction, which definitely made my heart sink a bit...) but he wasn't particularly positive on the idea of a second operation to try to repair the damage.  His thought was that he might be able to fix what surgeon #1 did by creating a new peroneus brevis out of my FHL tendon, but he felt there was a good chance I could come out of a second operation in even worse shape than I'm in now.  His advice was to only get the second operation done if I were very unhappy with my running ability after 9-12 months of rehab.  This was exactly the same advice I got from another good foot surgeon via email, so it's promising having the two opinions coincide.  I'm currently at 7 months post-op, and given the massive progress my foot has been making the past few weeks, I think it's unlikely I'll go for the second operation, unless running in the mountains proves to be too much for the current repair and it fails.

I'm never one for the whole "just be optimistic" outlook--you don't build new tendons out of optimism.  But I do have to mention one of the big positives that came out of this injury, and that is the people who were a part of my recovery.  That started right from day 1, when two now-friends who I had only known for 12 hours came to rescue me from the hospital on a cold winter night, followed shortly by Divesh rescuing me from my hotel room of doom. Then there was all the help and support from friends and family while I was on crutches, and finally there were the new people I met because of the injury, such as my injury twin Diana, and Jordi, the world's best physical therapist, who is a rehab expert and all-around excellent person rolled into one.  If there is at all a good part of being injured, this is it.

And now?  I've made a list of all of the things I missed out on while injured, and I'm going to be making my way through it over the coming months.  And if all goes really well...I'm entered in the 110km Ultra Pirineu for September 29.  Even 40km is currently a very long way for me, so I'll have to see what my ankle says about the idea of 110km in only a month's time, but if it's possible, I'll be there!

 

Peroneal tendon rupture, surgery, and rehab, part 2

It has only been two months since my post about part 1, and already it feels like several lifetimes have gone by...

Lifetime 1:  visit with surgeon #2 and improvements

Surgeon #2 was excellent and it was well worth going.  For a start, he gave me 15 minutes of uninterrupted appointment time, practically a miracle compared to my experience with surgeon #1.  Surgeon #2 was concerned about the fact that surgeon #1 had placed a tenodesis anchor right on the site of my metatarsal fracture and thought that might be the cause of all the pain.  He did an x-ray to check that the anchor hadn't caused the fracture to re-open, which fortunately showed that it hadn't, although it could still have been causing the pain.  However, surgeon #2 also did an ultrasound, which did show a large bone fragment stuck right next to the tendon repair, making it a prime candidate as a pain cause. 

The next month was full of slow, steady improvements.  Of course, there were plenty of "bad foot" days, and I still suffered from perma-red foot from all the inflammation, but it was definitely an upward trend.

The mental crux that I hadn't been expecting was the time period where I was able to walk but not yet able to walk far enough or fast enough to get any aerobic exercise.  As depressing as it was, I had to resign myself to going out on the crutches or the pegleg for the "exercise" portion of my activities, and then practice walking separately.

Somewhat ironically, I got less and less fit aerobically as my foot improved, since I started doing more walking and stopped doing my uphill crutching repeats!

Finally, at 13 weeks post-op, I did my first outing that could, if you were feeling unusually optimistic, be called a run:  5 miles on a vertical k course, mostly walking the steep uphill, running the gradual uphill, and running nearly all of the downhill.

Lifetime 2:  infection

The improvements came crashing to a halt when my surgical wound got infected at 13.5 weeks post-op.  An infection that shows up that late in the game is a very worrying thing, since it makes it highly likely that the infection is a deep one.  Cue total rest, elevating my leg, hours of frantic research and quality advice from the most qualified medic I know, and a trip to the doctor, who prescribed antibiotics and never managed to answer my question about when I should come for follow-up care if the infection didn't clear. 

It didn't clear.  After 5 days of antibiotics and no improvements, I sent a panicked email to surgeon #2, who was kind enough to look at a few photos of my foot and then told me to get it seen sooner rather than later.  Two days later, I was in surgeon #2's office.  He did an ultrasound to check if it might be a stitch abscess (it wasn't) and then confirmed what I had already suspected from my reading:  the doctor I had seen a week ago had prescribed an incorrect choice of antibiotic.  So I moved on to antibiotics round 2, took a deep breath, and talked myself into handling the mental pain of going back on crutches for exercising.

I'm not wearing the orthopedic boot because I need it for walking, I'm wearing it to prevent walking.  It's the runner equivalent of the cone of shame.

It's funny looking back on my changes in perspective since the injury.  When the accident happened on December 2, my first thought was "will I have enough time to train for Transgrancanaria?"  TGC is in late February!  After finding out I needed surgery and then getting delayed for a couple of months on that, my worry was whether or not I'd be able to race this summer.  After finding out I had been robbed of a key foot tendon whilst unconscious during surgery, I was concerned about whether I'd ever run on technical ground again.  And by late April, with a late-onset surgical site infection, I was ready to consider it a win if I didn't have to have my foot amputated.

Luckily for the chances of continued attachment of my foot, the second round of antibiotics worked, but...

Lifetime 3:  sural nerve issues

...getting rid of the infection did nothing to change the unbearable level of pain I'd been experiencing.  Neither did two weeks of total rest, so it was clear it wasn't a simple case of overdoing it on the newly-repaired tendon.  The type of pain--white-hot, coming and going in flashes--didn't feel like tendon pain, either, and I did more reading and starting thinking it could either be an allergic reaction to the biocomposite material in the tenodesis anchor (shows up, if it's going to happen, when the anchor starts to degrade around 3 months post-op, so the timing fit, plus the inflammation seemed to respond a bit to an antihistamine) or damage to the sural nerve. 

I finally deployed the weapon I should have deployed two weeks earlier:  a visit to my amazing physio.  He was almost sure the problem was with the sural nerve; it runs alongside the peroneal tendons and it's common for it to get damaged or entrapped in scar tissue after peroneal tendon surgery.  I left after an hour of serious poking and prodding to try to extricate the nerve, with instructions to perform twice daily exercises and to wait at least 5 days before trying to run.

And today, 5 days later...I ran!  Four repeats of 5 minutes each, on very flat and soft ground.  There was still definitely nerve pain going on but at a much more manageable level than before.  It's a start...

 

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!