Saturday, May 20, 2023

2 years post surgery for PTTD

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Originally Published in 2018.

When I left off, I mentioned I'd be getting some followup x-rays to assess whether or not my calcaneal non-union is stable or if there are any changes happening with it - (Also it seems I got totally distracted and never did post this a year ago when I started writing up this draft - I had a couple recent email exchanges with people who have had the surgery recently which made me realize I left off my updates to my blog!)  Anyhow, a photo is worth a thousand words or so they say - I was somewhat astonished to observe that it seems my non-union may be righting itself - it's impossible to confirm for sure without a CT, but it certainly looked that way from my followup 2-D x-rays. 
 
Where am I today 2+ years post surgery?  I'm still asymptomatic for the most part for anything related to my non-union, and I'm still regaining strength - it's challenging with a sedentary job and a general dislike for the gym.  I was even able to take a hiking vacation earlier this year where I was able to cover some decent mileage on off-camber slickrock! 
  
Am I completely pain free? More or less - as long as I don't overdo it and pay attention to what my body is trying to tell me.  I tend to wear minimalist zero-drop footwear most of the time, though sometimes I get some joint pain in the 2nd metatarsal region - I think it's because my foot just doesn't have the normal flex due to the fusion that was done at my first metatarsal and my gait might still be kinda wonky due to bad habits developed during rehab (pay attention to your gait while relearning how to walk post surgery!).  My calf sometimes winds itself pretty tight, and the only way I can get it to release is to do some myofascial massage (stretching does nothing for it).   When I start having pain, I wear a more supportive shoe, I take care to ice and rest my foot, and when needed, I wear compression socks. 
  
Am I footwear limited? Not really - For the most part, I can get into all the shoes that I was able to wear before I started having serious problems and was stuck with a brace.  The foot that was surgeried is more prone to inflammation, so I am careful to pay attention to how shoes fit in relation to the top of my foot.  For shoes that put pressure on the top of my foot, I purchased an instep shoe stretcher (or you can take your shoes to a cobbler) to help relieve pressure - the shoe stretcher works best on leather shoes, and when stretched slowly - it was a slow and iterative process, but I was able to salvage even my Danskos, which I thought I would have to sell since I couldn't even get my foot into the shoes any more due to the fusion that was done. 

  
Do I still have numbness? There are some areas, especially near incisions where I feel I have reduced feeling - but for the most part, I have recovered from most of the numbness that was induced as a result of the surgery. 
  
How about those scars? Overall, my scars have faded - they are still visible, some more than others, but they aren't super pigmented and could easily be covered with concealer if I was so motivated (I'm not). I'll try to remember to add to this post if I get additional questions from people - if you have questions about my experience with this surgery, please leave me a comment and I'll answer as best as I can.

That's going to leave a mark...my experience with PTTD - Months 3.5 onward

This is a continuation of another post that covered my history with PTTD, my surgery and post surgical updates through the first 14 weeks. 
  
3.5 months post surgery checkup: Uh oh.  During my routine check up, we've discovered a complication.  The screw going through the forward calcaneal osteotomy (for the lateral column lengthening) has broken and a gap has been observed between the allograft and the calcaneus.  A CT was ordered to study the degree of healing for all locations affected by the surgery. 

CT report indicates that the first metatarsal fusion is complete and the posterior calcaneal osteotomy (medial slide location) appears fully healed.  Unfortunately the forward osteotomy shows "no greater than 20% bone bridging" and as you can see in the inset image, there is a fairly significant gap present. Exact path for treatment is still to be determined by the my orthopedic surgeon, however due to timing, I am unable to get an appointment until approximately 4 months post surgery. 
 
When the damaged screw was discovered, I switched back to non-weightbearing (or very close to nonweight bearing) to minimize any further potential damage.  Some may wonder if I had any indication prior to the x-ray that something was wrong - I have a fairly high pain threshold and I have associated numbness in my foot due to the surgery and did not have any severe pain associated with the broken screw and failing bone graft.  I have had some sensitivity near the lower incision site on the outside of my foot,  presumably where they cut to make the osteotomies - the pain associated with this location was noticed while weight bearing (it felt like a bit of a prickling sensation on the outside edge of my foot near the surgical site), but more so during scar tissue release during physical therapy - I had been thinking it was more related to the sural nerve possibly being caught up in scar tissue.  After having been off my foot for about a week as of this writing, I do notice some discomfort in that region even while not weight bearing. 

4 months post surgery followup: Met for a followup with the surgeon to review my CT scan results - CT is showing minimal healing of the forward (Evans) osteotomy - basically the graft is not healing well to my calcaneus.  I don't have any significant pain when I try to walk on the foot, so I've been encouraged to continue with PT while wearing supportive shoes and at the same time I've been advised to really pay close attention to how my foot feels - so no pushing through pain.  Things I've discovered since the CT: 1) I am low on Vitamin D and 2) possibly also low in blood calcium level.  I've added a Vitamin D3 supplement (curiously, the Vitamin D3 can be derived from sheeps wool....and more specifically from lanolin from sheeps wool!)  and have also added a calcium supplement (by way of Calcium Citrate powder - which, for me, is easier to deal with than trying to swallow a gigantic calcium pill).  The surgeon has also ordered a bone growth stimulator to try to help with my bone nonunion situation.  Apparently the presence of the non-union or the broken screw are not necessarily reasons to panic, or so says a 2nd surgeon who I went to see for a consult. The consulting surgeon agreed that my treatment plan is appropriate, and also encouraged me to walk on the foot while being cognizant of  any pain or discomfort that could be related to the nonunion.  

Obtaining the bone growth stimulator took a little while - there was an initial delay getting the order from the surgeon's office to the DME supplier (presumably because it takes a while to compile the supporting notes to justify the order).  Once the DME supplier had the order in hand, they had to submit it to my insurance to determine if it was covered or not.  Presumably they got the approval, though I haven't seen the EOB post just yet.  It was shipped directly from the manufacturer to me.  Use of the device is fairly straight forward, once I received clarification on where to place the transducer (which apparently has a beam approximately 5cm wide). 

5 months post surgery: No significant differences observed in my X-ray, and I'm back to walking on the foot though my gait is still not quite right.  I've been advised to wear supportive footwear at all times, though honestly, I feel that restriction is significantly hindering my ability to relearn a normal gait since a lot of my problems seem to stem from the fact that I don't have control over the small muscles in my foot - the short distances I've walked barefoot (to go get the x-rays done, for example) highlight this in that my foot strike is completely screwed up, and my foot acts rather "blocky" for lack of a better way to put it.  Transitioning weight through the foot does not seem to happen very naturally and I definitely cannot balance on my post surgical foot as the muscles are extremely weak and don't seem to know how to respond as weight is transitioned to my fore-foot.  For short distances I am okay walking without assistance, though further distances and prolonged standing still make my foot cranky.  As far as PT goes, I've progressed to strength and balance training using bodyweight.  The goal over the next month is to be able to walk consistently without needing to bring my crutch/cane around. 
 
 6 months post surgery: Bad news first - I had a followup CT to gauge the status of my slow-healing osteotomy and it seems like things are not progressing terribly well...I think the report states it quite clearly in that the "majority of bone graft remains unincorporated with no solid bridging across the osteotomy."  Reviewing the scan with the surgeon, it looks like the cadaver bone is being slowly absorbed by my body, but for whatever reason, my body is being rather stubborn about generating new bone tissue to incorporate the allograft, but I'm still hopeful that maybe it will change its mind with continued Vitamin D, Calcium and use of the bone growth stimulator.  Unfortunately if things continue and my foot starts showing signs of collapse or misalignment, the only recourse seems to be another surgery. 

The happier news is that I seem to be relatively asymptomatic for having a potential nonunion.  My gait has smoothed out a lot, though is not completely balanced and I continue have an occasional limp.  Strength is slowly returning as I continue to work on that along with balance. In addition to doing some ankle stability exercises on the floor, I also have a balance disk (though I certainly cannot stand single footed on that without aid) and a balance board (I use this one with both feet on it - and always while standing near something that I can grab for support).  I can do dual leg body-weight calf raises, but I don't have enough strength to manage doing single legged raises (or to walk on my toes for that matter).  Progress seems to be moving along again, and I've been cleared to start trying to get back to "normal" activities and footwear (or no footwear if that is my preference) to see if my foot and ankle will tolerate those things.  I find my pains these days to not be consistently concentrated in any specific location - they seem to move around as my muscles are continuing to relearn just what all they should be doing. 

I've attempted to try some of my other shoes on now that my foot no longer seems to have excessive swelling - I've noticed that the metatarsal fusion has definitely changed my instep height, but thankfully it does not appear that my overall foot length has not changed - at least not enough for me to notice with the few pairs of shoes/boots I've tried on.  I'm not sure if I will ever be able to get back into some shoes/boots - I'm hoping with time any additional swelling will leave and the scar and tendons on top of my foot will become less sensitive to pressure - otherwise I'm going to be mourning the loss of several pairs of lovely shoes and boots including my beloved red Doc Martens. 
  
8.5 months post surgery: They did warn me that this could take up to a year to recover (and possibly more since I had a delay in my therapy when the broken hardware and non-union were discovered).  While my gait remains mostly normal, I have continued to notice that my left foot still seems swollen compared to my right.  I switched up my lacing on my shoes so they match again (I had previously left the midfoot of my left shoes unlaced (Gap Lacing)) - and noticed the lacing on the left shoes had to be done more loosely to accomodate my foot.  Curiosity got me, and I did a water displacement test:

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Surprisingly, or perhaps not, my left foot displaced 88g or about 3 oz more water than the right.  3 oz is about the volume of a deck of cards, in case you are wondering.  Activity wise, I can walk further now, and can handle relatively flat well maintained trails - but I can't cover the kind of distances I could before the surgery without the foot complaining.  My single leg balance is getting better, though is still rather wobbly - and I still cannot manage single leg calf raises or walking on my toes. 

10 months post surgery: Toe walking achieved!  Not for very long durations and not without shoes but still...progress! Single leg calf raises are still a nonstarter without being able to take some of my body weight off by pressing on a counter, but I'm making slow progress.

 

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In addition to the toe walking, I've managed to take a couple short hikes on much more challenging terrain.  Often, my foot will swell later in the day or the day afterwards in protest, but as I gain strength in the muscles, I expect to be able to increase mileage and difficulty in terrain. 
 
I recently did another volume displacement check and my left foot is now within 17g or 0.6oz (just over 1 tablespoon) of my right foot.  I did not think to check the volumes of my feet before I had surgery and I honestly can't remember which foot has historically been the larger one.  My calves are still noticeably different - while muscle tone is coming back, I am still lacking a significant amount of muscle mass in the left calf (it remains about an inch smaller in circumference than the right calf or my pre-surgery left-calf measurement). 

I remain asymptomatic for the nonunion as far as I can tell, though I'm starting to get weird sensations around my various incisions - I think the nerves are coming back and I'm regaining feeling where there was numbness before.  I have a followup CT scheduled in another few weeks; in the meantime, I will continue trying to improve my balance and strength in my left foot/ankle. 

11 months post surgery:  Followup CT completed - and I've officially got myself a fibrous nonunion.  The good news is I am relatively asymptomatic - I have some fleeting pain around my scars, and I still get muscle soreness and occasional flare ups of my plantar fascia and disperse prickliness for lack of any better way to describe it, but there is little localized pain related to the nonunion.  On occasion I get pain at my subtalar talar and talar fibular joints but, nothing high enough to cause me concern. 

Where does the path go from here? Surgical consultations leave me with 2 options: The first is a revision surgery - where they would go back in and "redo" the evans osteotomy graft.  They can graft it with autograft harvested from my iliac crest - or they can do an allograft again...or there are metal wedges (both porous and non) that could be inserted.  For fixation, it could be via screws (similar to last time) or plate - though a plate can cause irritation of the peroneal tendons...downtime would include up to 3 months of non weight bearing in a cast or boot.   And after all that, I could still be stuck with yet another nonunion.  The second option is do nothing - and basically continue to monitor.  It seems some of the weakness I have is to be expected, especially with my calf (which is still noticeably smaller when compared to my other leg) - the calf weakness is likely due to the gastroc release (which resulted in lengthening my calf muscle and therefore making it less effective). 

I'm a bit leery of hobbling about with a gap in my calcaneus, but I've been advised that orthopedic surgeons generally operate to try to reduce pain, and not just to address a perceived issue in a radiograph.  My primary concern is that my heel will continue to move, since the calcaneus is no longer in one piece but if two independent surgeons warn you off a surgery, it's best to take heed.  I'll be following up down the road with yet more x-rays to make sure nothing has moved significantly, while in the meantime I'll probably need to make nice with the gym to try to regain muscle strength faster.  I've been advised to go on with my life and pick up all my activities and see what limitations (if any) remain after I regain strength - apparently it is not completely abnormal to have an asymptomatic nonunion at the evans osteotomy site if it's done correctly, so hooray for that.

Some things to have on hand in case of foot/ankle surgery

Getting ready for surgery I made a bunch of purchases in an attempt to make my life a little easier - if you're having a foot or ankle surgery the following items may make your life a bit easier while healing:
  • Knee Scooter - Mine was covered through insurance, though this is the same model that I have - it's not perfect, but it makes moving around much easier (when compared to crutches) if you happen to have a mostly hard surface flooring home.
    • Knee Scooter Cover - not a necessity, but provides a bit of additional padding (and helps with sweat absorption).  All covers I found were synthetic and did not breathe really well, and mine became matted within a couple weeks of use - but it was better than the bare pad of the knee scooter.
    • Basket for Knee Scooter - this basket is for a bike, but I was able to mount it on my knee scooter to help carry light things around.
  • Forearm Crutches - I opted for forearm crutches rather than standard crutches.  They are harder to use, but don't result in pinching or chafing under the arms like standard crutches can.  The model I have is not available on amazon (mine were issued through a medical supply company). Once I learned how to use them properly, I've found them to be comfortable in use.
  • Shower Bench - this was a must for bathing and showering since I could not put weight on my foot (and even with the cast off, I did not put weight on the foot without the walking boot until cleared to do so).  This one was easy to assemble and had a large range in adjustable height.  While used in the bathtub, I was able to sit on it comfortably while keeping my surgical dressed leg out of the tub without putting undue pressure on it. In the shower, I use it by putting the knee of my surgical leg on it, in a similar fashion to how I use the knee scooter.  If your bathroom is not equipped with grab bars, it may be advisable to get some temporary ones - my shower had grab bars already installed by the previous owners, and I found them very helpful.
  • Cast Cover - much better than using a garbage bag or saran wrap - I only used this once I was in an actual cast as the seal is quite tight and I was worried about disturbing the surgical dressing.  Be careful, as this model is quite long (can probably accomodate over the knee use - so for lower leg casts only there is a lot of excess "cover" dangling about).
  • Leg elevation Pillow - not a must have, but was certainly more stable than stacked pillows and cushions.  On its own, it was not tall enough to elevate at or above heart level so I wound up augmenting it with throw pillows underneath while sitting on the couch.
Things you may want when the cast comes off:
  • No Rinse Bath Wash - also would be helpful if you're having issues getting a bath/shower.
  • Steri Strips and tincture of benzoin to help them stick - in case some of your incisions aren't quite healed when the cast comes off.  I had to replace some of my steristrips before the incision was healed up completely.
  • Compression Socks - I'm partial to Sockwell brand but there are a lot of different kinds out there made for runners - make sure you check the sizing for both foot size and calf circumference.  I wore compression socks with my walking boot to help reduce swelling.  I continue to wear them even after I've graduated out of the walking boot as I've been advised to expect swelling and discoloration for up to 6 months post surgery.

That's going to leave a mark...my experience with PTTD

Warning: This is a super long post...long enough that it seems it keeps crashing my blog when I try to publish it in its entirety. I've put in "bookmarks" in case you want to hop directly to an area of interest.  In short, I created this entry (which has been broken into 3 pieces) to describe my experience with PTTD, its treatment and my outcome - these ramblings span almost a year, and are all together rather long as a result.  I put it together in hopes that others find it useful. 

Originally published in autumn of 2016 at another blog location, but I was letting my domain expire, so I wanted to move this elsewhere where folks might still be able to find it.

Miscellaneous notes and comments - things you might want on hand if you're having foot/ankle surgery

Personal history: I used to spend lots of time hiking both on trail and off, as well as doing a fair bit of canyoneering.  As I got older and into more sedentary jobs, I struggled with added weight.  I used to run, having completed some 5k runs and a half marathon....at the same time, as far as I can remember, I've had issues with my knees and ankles.  I've had custom orthotics for years - probably as far back as 2005 - I have a variety of them, posted and non-posted, full length, and 3/4 length, covered and non-covered.  If I think back to my experience with physical therapists I've been treated for ankle injuries before, knee issues compounded with IT band problems, severe shin splints and plantar fasciitis....luckily not all on both legs ;)  For me, it seems my left leg has been prone to ankle issues while my right has suffered the brunt of the other injuries including plantar fasciitis, shin splints, a maltracking patella and horrendous IT band tightness.  A number of these issues have to do with my body's biomechanics - I have a lot of slop in my joints and tend to hit the end of my range of motion before I ever feel a stretch to my muscles. 

So, how did I wind up with all this hardware in my foot? 

It all started over four years ago - and quite possibly even longer before then, however four years ago I have definitive evidence by way of MRI imaging that I had damaged my posterior tibial tendon.  How did I do it? I blame a treadmill, but it could have been any number of things since I tended to do a lot of off trail hiking back then.  Interestingly (to me anyhow) my MRI also revealed that indeed seem to have sprained my calcaneofibular and anterior talofibular ligaments.  I had also managed to partially tear my deltoid ligament but apparently did it while I was young enough to heal it.  Basically, I had evidence in my MRI that I had significantly borked my ankle on both medial and lateral sides previously. 

Anyhow, four years ago I had suffered some pain on the inside of my ankle and it wasn't getting any better - I hied myself off to my sports med doc and an MRI was ordered, highlighting a low to intermediate grade interstitial partial tear in my posterior tibial tendon near its insertion point.  The recommended treatment course was to get refitted for orthotics, get fitted for a custom ankle brace that restricted lateral movement of my ankle, and complete a round of physical therapy.  I did all of the above, and was pain free for about two and a half years. 

After two and a half years of pain free living, I started getting worsening plantar fasciitis pain and it eventually got bad enough that getting up on my feet after sitting for a while resulted in a limp until I got things warmed back up again.  My doctor recommended a round of physical therapy (PT) to treat it - PT helped quite a bit, getting me to the point where I no longer was experiencing plantar fasciitis pain - instead, I was more aware of some nagging pain on the inside of my ankle, where the posterior tibial tendon is located.  Sure enough, my physical therapist also observed a fair bit of swelling in that region, and suggested I follow up with my doctor.  A followup MRI was ordered and the results were not favorable - the tear that was found previously had not healed and instead was worsening. 

What does all this mean? The official diagnosis is Posterior Tibial Tendon Dysfunction (PTTD) -  also known as Adult Acquired Flat Foot.  Strangely enough, I've always had fairly flat feet - but the tear in my post tib tendon was causing my left arch to fall and eventually it could have completely collapsed, resulting in arthritis and a significant amount of pain.  Unfortunately for me, at this point I had exhausted all non invasive treatments and was advised to 1) always wear my ankle brace and 2) start getting opinions from other specialists on treatment.

 

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A multitude of specialists were consulted and nearly all agreed on the recommended treatment plan: surgical repair/replacement of the tendon and rebuilding the arch of my affected foot.  One doctor suggested one additional minimally invasive treatment (Platelet Rich Plasma (PRP) injection therapy) prior to trying surgery, however PRP is not an approved treatment in the US, and I could not find any significant literature on it for injuries of my type.  In addition, recovery would have involved being in a walking boot for 6 weeks and if the injury was not repaired, I would have to go down the path of surgery anyway. 

 As you've likely surmised, I opted for surgery.  I wore my brace daily until surgery to try to minimize any further damage to the tendon, however it seems the tendon in question was so badly damaged that they did not repair it, but removed it altogether.  What all is involved in the surgery?  In medical terms, it included the following: medial slide calcaneal osteotomy, lateral column lengthening, TMT fusion, Flexor Digitorum Longus transfer and spring ligament repair, and gastroc recession.  In laymen's terms: they cut my heel in 2 places, moved it over towards the center of my body, added some length to it and screwed it in place; fused my first metatarsal joint (the joint was hypermobile and was allowing my arch to collapse - without fusing it I risk damaging the transferred tendon); the damaged post tib tendon was removed and the flexor digitorum longus was transferred to act in its place; my calf muscle was released/lengthened to accommodate the new position of my heel and to not yank on the newly transferred tendon.  All of this resulted in six incisions, eight screws, one plate, a bone shim from a cadaver's illiac crest and a whole lot of stitches. Trust me, it was gruesome.

The surgery itself took about two and a half hours to complete - I was out under general anesthesia in addition to a popliteal nerve block.  There was an option for this to be an outpatient treatment, however I was admitted overnight for monitoring because I did not take to the anesthesia well at all - I suffered severe nausea well into the early morning hours after the surgery, and it took several different antiemetics to get things under control.  Similarly, I apparently don't tolerate prescription pain killers terribly well either, as those also left me with nausea, requiring regular doses of phenergan (which basically worked as an antiemetic by knocking me out).   I weaned myself off the prescription pain medications in less than a week after the surgery, and continued to manage the pain over the next few weeks using ibuprofen, aspirin and acetaminophen (cutting back to only aspirin and ibuprofen as the pain reduced). 

Other than the nausea, which I knew to expect, another side effect of the anesthesia and/or post surgery medications was general brain fog and a complete inability to concentrate.  I had thought that since I was going to be immobile and on the couch with my leg elevated to heart level that I was going to to need to make sure to have lots of things near by to keep me occupied - I pre-prepped piles of reading material, yarn crafts and hand sewing projects.  In reality, for the first I was only able to work on a very simple (and ultimately mindless) blanket project which had been in hibernation for years (due mostly in part to how non-engaging and repetitive a project it was).   At around the 3.5 - 4 week point, the fog started to clear...timing wise this was just about perfect as I finally got the blanket done to an appropriate size to finish it off (and was starting to get bored with it again)!

 

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0-1 week after surgery: Leg was wrapped in surgical dressing and splint. Foot/Ankle was elevated to heart level or higher to promote healing and reduce swelling. Bathing was done by supporting the splint outside the bathtub, while using a pitcher to pour water over myself - I didn't want to try to get a cast cover on over the soft dressing so resorted to this method of bathing.  If not obvious, my leg was non-weight bearing (NWB) during this time. 

1 Week after surgery: Post surgical soft dressing and splint was removed, incisions inspected and I was put into a cast.  I've never had a cast before, and wasn't sure what to expect - I was surprised to discover I had a palette to select from (including a glow in the dark option!).  Foot was remarkably bruised and swollen, but I was assured that it was the appropriate level of gruesome given what all was done to it during the surgery. 

1-3 weeks after surgery: Continued to elevate leg at or above heart level, for the most part, remained benched with no excursions out of the house to speak of (still NWB). Towards the latter portion of this timeframe, my leg started to itch inside the cast - it is not advised to put things inside the cast, but luckily for me, my leg had atrophied/reduced swelling enough that I could reach my hand in from the top of the cast to get a bit of relief. 

3 weeks after surgery: Stitches removed, steri-strips and new cast applied (red and black with glitter).  There was still a surprising amount of swelling and bruising, though I was assured that that was completely normal.  I brought some old washcloths and no-rinse bath wash with me to my appointment so I could try to clean my leg somewhat since it had been locked up in a dressing or cast for the previous 3 weeks.  It was good to scrub off some of the marker and iodine that was put on the leg during the course of the surgery, and in general it was good to get the sweat off of it.

 

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3-6 weeks after surgery
: Longer bouts with the leg not elevated, though for all intents and purposes I was still couch bound with my leg elevated at/above heart level and still NWB.  Unfortunately, my ankle started to itch more regularly with this cast - likely a combination of the healing process and slight dampness.  I had been advised that a vacuum could help relieve itching.  There is even a commercial product out there that uses a vinyl band and a vacuum port to help cool down a cast - I wasn't super thrilled with the asking price, so I had a look at what I had available to me at home - my solution involved an old theraband (that red wrapped around the ankle of the cast) and a toilet paper tube.  I cut the tube to make sure I could get it to fit tightly around the hose of my vacuum, and also cut fins or flaps into one end of the tube, opening them outward and securing them on the inside of the theraband to ensure a good seal - this helped with the itching somewhat, and had I used my shop vac, I would have been able to draw more air through.  The theraband and toilet paper tube help to really localize the suction from the vacuum - pulling cooler ambient air through the cast surprisingly (to me) help reduce the itching. 
 
6 weeks after surgery: Cast Removed! My foot was still remarkably purple and bruised, and my calf was significantly atrophied (and very flabby and spongy in texture).  Overall in six weeks, my calf shrank by about two inches at its largest point.  The incisions, for the most part, were healed - with the exception of the one on the very top of my foot (where the plate went in) - that one still had a little bit to go, so they steri-stripped it. Lest you think I was turned loose at this point with no more hardware, I was issued a walking boot, a soft plantar fasciitis night splint, a PT prescription, a recommendation for over the counter arch support for use inside the walking boot (I went with a superfeet blue insert - I'll have to see with time if I should have gone with the green instead) and was told to transition to partial weight bearing on the surgical foot with the goal of getting to full weight bearing over the next couple weeks. 

 One thing that no one really mentioned was just how much skin was going to be sloughing off once the cast was removed.  Since I still had one incision that wasn't fully healed, I was advised to not soak the leg (showering was fine but immersing it in a tub for a long period of time was not recommended).  To facilitate exfoliation, I wrapped my lower leg and foot in a damp towel (except the incision that was steri-stripped) and then used a combination of a washcloth and pumice sponge to help remove the dead skin.  I also liberally applied moisturizer and wore a sock.  Whenever my skin or healed incisions got itchy I tried not to scratch, but would sometimes dry brush, apply cortisone cream or apply an ice pack to relieve the itching. 

Over the weekend, I started hobbling around on my crutches while starting to put weight on my foot - I have to admit, crutching while partial weight bearing was significantly easier than crutching while non weight bearing...even if I wasn't putting much weight down on my foot, it was easier than holding it up off the ground completely.  The goal was to gradually increase the % of my bodyweight being put on the foot to about 50% over the course of the following week. 

Physical therapy started bright and early the Monday after the cast was removed.  Range of motion in my ankle had reduced to nearly nothing.  Initial exercises assigned were for active range of motion in the ankle (including flexion, extension, inversion and eversion), small foot muscles (arch raises and toe yoga) and I was reintroduced to the BAPS board - because my range of motion had been so significantly reduced, successfully using the BAPS board even on its smallest setting was a challenge. Additional exercises were also assigned for my quads, hamstrings, hips and core - mostly to try to get things back in shape after not being used properly for 6+ weeks.

 

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7 weeks post surgery
: Remaining Steri strips were removed from the incision on the top of my foot.  Physical therapy continues, continuing to work active range of motion in ankle while also receiving manual treatment on scar tissue and muscles as they start to be more engaged with walking.  Cleared to attempt 1 crutch walking to facilitate transition to full weight bearing over the course of the following week. 

One thing they don't warn you about while being stuck with a walking boot, is that the sole is quite tall - finding footwear that matches for heel height is a bit of a challenge.  It seems for me, my best bet is my danskos with a custom orthotic and heel lift inside or my old moto boot. 

Transitioning to walking on a single crutch was not too difficult, though I do note discomfort under my heel and sometimes on the outside of my foot - I suspect these are both related to scar tissue and continued healing of the calcaneus. 

 8 weeks post surgery: By the beginning of the 8th week post surgery, I have successfully transitioned to full weight bearing on occasion but still assisted with single crutch in the morning, or if the distance is significant or if experiencing a pain flare up. Most bruising and discoloration has finally faded, though there is still some swelling compared to my other foot.  Ankle flexion and extension range of motion significantly improved, though significant tightness is now appearing in foot, and lower leg (calf and shin) as use is increased.  Biggest concern is overuse resulting in tendinitis - have been advised to not rush into walking too much if it is resulting in significant pain which will slow or stall progress.  Exercises remain non-weight/resistance bearing though I have added calf stretches and seated heel and toe raises while also progressing to the next level on the BAPS board. 
 
9 weeks post surgery: I still notice swelling and discoloration when compared to my other foot/leg.  By the beginning of the 9th week post surgery, I am consistently making my way around without the aid of a crutch and have been cleared to stand still on both feet to start working on proprioception and start getting the muscles in my foot to realize the vacation is over. (My foot is still confined in a walking boot during the day and a splint at night.)  I'm also continuing with active range of motion exercises, adding ankle circles and alphabet drawing.  I've also managed to advance to the middle sized hemisphere on the BAPS board! 

Standing on the surgical foot has been a strange experience - the floor usually feels much cooler to that foot (due to the difference in blood flow between my feet, I suspect) - and it often feels like there is something strange going on beneath my heel (other than the 2 monstrous screws that were inserted).  I suspect this has to do with heel tissue atrophy while I was nonweight bearing combined with scar tissue and general numbness in certain regions due to surgically induced nerve damage that has yet to repair itself. 

 10 weeks post surgery:  Graduated out of the walking boot and into a sturdy shoe and ankle brace (and also cleared from the night splint)!  During my check-up I had to take a few steps without boot or brace to get weight bearing x-rays done and I have to say, my ankle is really really weak.  As you may have surmised from the photo, I have taken up the crutch again while I make the transition into the ankle brace and shoes.  The goal over the next month will be to eventually transition out of the ankle brace and into a supportive shoe. 

As you might guess, the brace is somewhat bulky, necessitating a trial of shoes again to accommodate.  Unlike my rigid brace this one adds bulk to my midfoot (on top of the swelling that is also present). In addition, since I had my calf lengthened during the surgery, I have also been encouraged to find a pair of supportive zero-drop shoes to help encourage my calf to stay lengthened and also to help strengthen my feet.  Normally transitioning to a zero-drop shoe takes some time, however relearning how to walk after two months of not walking makes some things a bit easier....my walking gait is actually rather screwed up right now since I picked up some bad habits while in the walking boot that result in a lurching and swaying gait.  

I auditioned all the shoes in my closet to check for fit and to try to select a pair for in house and out-of-house use.  Starting in the lower left, my black trail runners fit, but they have a considerable ramp height from heel to toe - so I ruled them out.  In the upper left, I have a pair of weird looking rubbery shoes (made by a company that is no longer in business) - they are sturdy and easy to slip on and off, but they also have a fairly significant heel-toe drop (it seems most "flats" actually have a 10-15mm drop) - they will do for house shoes until I secure some zero-drop shoes to press into service.  The closest shoe I have to a zero drop shoe are the bright orange brooks - these have been languishing in my closet for some time due to injury and other things (I think the current model of this shoe is on it's 5th generation) - they have a 4mm drop - unfortunately, due to swelling in my foot, they are rather uncomfortable through the midfoot. 
 
After pinging various running friends I settled on a brand I had heard of, but had not tried: Altra.  Altra makes a line of cushioned zero drop shoes (and there are many brands that make low drop shoes in the 4mm range)  One of the things I like best about the Altras though is the wide toe box, which accommodate my feet nicely without any pressure on my toes - it's the same reason I like Keens so much. 

As for progress and pain, my range of motion is coming back, though I feel some pain in the ankle joint as I have started to use it again - I suspect this is the ligaments getting re-accustomed to being pressed into service.  At 10 weeks, I still have not started active strengthening exercises, but have been adding some additional proprioception exercises (with shoes on) to help retrain my gait.  Over the next few weeks, I expect to add some light resistance to my exercises by way of a theraband (starting with yellow). 
 
 Weeks 11 & 12 post surgery: I'm officially back to work and my foot is officially cranky about the situation and generally displays a fair bit of inflammation by the end of the day (and some pretty spectacular purpling too).  As a result, I've not yet completely abandoned the crutch, though I try to walk around in the office area without it.  My gait continues to be "strange" and requires conscious effort to be remotely balanced, and I still tend to strike on the outside of my surgery foot and have a hard time getting over onto the big-toe / first metatarsal side of the ball of my foot when toeing off. 

I've been wearing two different kind of Altras - I have a pair of house shoes (Altra Superior 2 - they are actually trail runners, but with "light cushioning") - for out of the house, I have been wearing Altra Provision 2.5s with "moderate cushioning".  The Provision is a "guidance" or stability shoe - and lately I've noticed that it feels like it might be working against me as far as my getting my gait in order with a proper toe-off - so I've switched to the Intuition 3.5, which is a neutral gait "moderate cushioned" shoe (also made by Altra).  Interestingly, I think I could actually feel the stability wedge at work in the Provisions when I put them on after changing out from the Superiors in the morning.  Hopefully the Intuition gets me on the right track for my gait. 

Weeks 13 & 14 post surgery:  Shoe news: the Altra Intuitions definitely feel more level and my gait is slowly getting better.  I've been cleared to stop using the ankle brace and have started adding some additional exercises to increase ankle mobility as well as start working on strength/stability.  Resistance/theraband exercises have been assigned (flexion, extension, inversion and eversion) using the yellow theraband in addition to some single leg balance exercises and heel-toe walking.

 

A photo posted by Stephanie (@woodlandsprite) on


I definitely still don't load the foot properly and have difficulty getting weight down through the forefoot - it's especially obvious when either standing on a foam balance pad or a balance disk.  I'm still working on waking up all the muscles in my foot to correct this. 

Crutch/Cane update: Since returning to work, I have been carrying 1 crutch in for use - often I am able to go short distances/periods unassisted.  At home, I generally get around without any crutch or cane assistance.  Gait is smoothing out and getting to be more normal, though I still have to actively think about foot strike and transition through for toe-off.