Wednesday, May 16, 2018

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...