Avulsion for once

I hadn’t realized that I haven’t posted since the beginning of October 2009, but then little remarkable has happened since then anyway, just enough that I’ve some last little pearls of wisdom.

Don’t wear boots!

Once you’re told to go FWB and into two shoes, make sure they are shoes. I wen’t to wearing the Catapillar Alaska’s right away and hadn’t realized that I was hampering my recovery for months. With all that extra support around the ankle I stopped developing strength long before I should have. I’m now in two shoes, aided most thoughtfully by my boots actually falling apart.

There can be too much support!

While preparing for this post I was reading some of the stuff from newcomers and noticed that there are some common threads about pain with the Plantar’s tendon. I too had that and it was a suggestion from my personal trainer that I get rid of the extra support in my boots that I credit for the pain going away. I’d been getting twinges and a couple of charlie horses in my sole but once I got rid of the added support those pains went away almost immediately.

Keep Moving!

I have said it before and I’ll say it to anyone who cares to listen, the worst thing to do with this injury is stop moving. Walking won’t hurt but climbing stairs, walking hills, hiking, cycling and most winter sports would be much more beneficial. Stretching that damnable tendon is necessary, especially if the internal sutures are left in place.

Do what you promise yourself

Simple, straightforward and you avoid regrets as well as make things happen. Even a year on I’ll get little jabs of depression because of the things that I didn’t do when the injury gave me the opportunity.

Relate

Don’t let things sink in, take advantage of any support systems that you have in place and talk about what you’re going through. Those close to you will be affected most and you may think that you’ve hidden your depression and anger well, but it’ll come out. You may even think that people should just take it as rote that you will be depressed and angry, but if you’re hiding it they may not realize just how much you are affected. Relate to someone, get it out in the open and let it heal. Like a poorly closed suture emotional wounds need to drain before they can close.

Prompted

Today was the first day I rode my bike outside. Its been almost 65 weeks since the injury and 67 weeks since I last rode outside. Its so much better than riding indoors and it was such a gorgeous day I’m really glad I did it. Amazingly there was also a considerable difference in how the tendon felt when riding in the wild rather than on the trainer. The gait, posture and angles all changed and I could feel the tightness in the tendon. Feels good though, now.

This should be it, likely the last post, but I’ll try to keep up with any notifications.

My best to you all and remember to keep your feet under you.

Tim

music inspiring this post: The Fixx, Shuttered Room; The Cure, Faith; Pukka Orchestra, Pukka Orchestra

Oct 1^st - Simple Progress

There isn’t much left to report on so at best I’ll probably be dropping down to monthly posts - if that often. Nothing spectacular or stunning is happening and progress is slow so not exciting.

I’ve started back at the gym twice a week, once with a trainer and once on my own. I also have decided to do as much as boredom will allow me to do on the bike trainer. Its deadly dull but its the best thing I’ve got in the house to help me rebuild my calf, if I can manage a half-hour a day or more I should be back to the strength I need to get back to commuting by mid November, after the death of Darcy Sheppard I’m actually looking forward to getting back on the road, I know at least one aggressive driver is off the road for a while.

Unlike most of the people I read here I’m not involved with a Physiotherapist in any capacity, my personal trainer does know a fair bit but it isn’t his forte. My initial idea is to follow the protocol outlined by the Carleton University Sports Medicine Clinic for the rehab for Chronic Achilles Tendinitis. Which is ironic because I suffer from that in my left foot.

My surgeon was understandably conservative with my rehabilitation, what with considering my age… rotten bugger. But I believe this is the first time he’s done a repair on an Achilles Avulsion which also made him a little more conservative. Apparently I am supposed to avoid gastrocnemius-soleus strengthening exercises ie calf-raises, but I’m pretending that I haven’t heard that. My surgeon did say I was ready to return to the mosh pit…

The waste and profile of my calf have pretty much returned to my pre-injury look, but the strength is definitely lacking - I’d put it at about 40% of what I expect. Still I’m hoping the cycling will handle that - I’m a hill climber (at least in comparison to the other aero-bellied old men I ride with) so I want that strength back soonish.

If I get enough sleep then I typically can make it through the first half of a work day without pain, without the limp and without needing the handrail’s assistance on the stairs.  I’m hoping that between a change in schedule at work, a more disciplined attitude towards food (and beverage) and more physical activity I’ll achieve something.

As it stands I continue to rip my LPs, try to figure out how to get Garmin Connect to accept rides that don’t have GPS data and rebuild a kitchen table.

Pictures

The bulk of the suture as it appears after a day of walking around.

This is what the scar looks like 6 months on. There happens to be a little irritation but thats because I spent the whole day walking around in steel toe boots before taking this picture. There is a tiny bit of swelling but the bulk of the misshapeness is from the sutures and suture pins.

Notice that the holes that were drilled through my heel are completely gone. not even a scar left.

The heel, all healed. In fact there is no indication that there were two holes drilled through my foot 6 months ago, and that even though I haven’t built the callous back up!

music used to inspire this post - public enemy ‘millennium collection’, nine inch nails ‘pretty hate machine’, the prodigy ‘experience’, metric ‘fantasies

June 5^th - September 10^th

So after walking out of the clinic with permission to go two shoes I wandered back to the office by way of the local food court for a little celebratory lunch. I got back to my desk sat down and immediately took off the boot and tried on my shoe. Luckily I had gone shoe shopping on the previous weekend. I’d tried on my work shoes and they were both too small and seemed to crush my heel with a vice like grip. So I get back to my desk, pull my right shoe out of my backpack and fit it on. Pretty much free now.

Putting the shoe on was liberating, working the rest of the day was exceptional but taking transit home that night was sobering. I no longer had anything to mark me as requiring assistance - you certainly don’t garner much sympathy for carrying an aircast. And it hurt, there was some swelling and the strength wasn’t there and there really wasn’t much I could do about the limp.

For the next week I worked into going to the shoes full time. It was mostly because I wanted to keep myself from over-reaching. I figured to show some improvement my muscles would need extra rest, so I took a couple of days wearing the aircast for transit but otherwise use the shoes or sandals or go barefoot.

So I got my birthday wish.

I also now get to go grocery shopping on my own, work in the yard without assistance, fetch things from the kitchen or the basement - pretty much loosing the hand-and-foot waiting on I’d been getting. But I also was now able to ride my bike in the trainer and spend some time trying to regain the fitness I had allowed to disappear when I stopped using the crutches, and to start trying to lose the 30 lbs that I gained at the same time.

My mother’s birthday is in July which proved to be my first test of endurance, its a 3.5 hour drive and except for a stop for Tim Hortons I made it all the way without an issue, the next day the same.

August is the month of an annual conference that my friends and I go to, typically without our wives but this year they tagged along meaning that a second vehicle was required. For people who like driving I would highly recommend the Ford Flex, it was exceptionally comfortable, except in the last row which is essentially a cushioned pit. Still I drove all 8 hours down and back which was good. There was also 5 to 7 hours of walking and standing required every day, which made the hot tub and the pool at the hotel very welcome.

I did experience some swelling at the end of those days, but it was nowhere near the swelling I experienced when visiting my brother a month earlier and standing on his back stoop chatting until 3am - my foot ballooned around the straps of my sandal looking for all the world like a loaf of white bread rising. That was the last significant swelling I experienced.

Part of the walking around the conference floor I spent concentrating on recovering my gait and eliminating my limp but by day 3 the leg was tired enough that I did stop off at a both and purchase a cane, which helped considerably. I tried to get over to see the Indianapolis Criterium to support the US bike culture and maybe see some shiny new toys before Interbike but we left late, it was a long walk and my leg really did not want to go that far. I’m disappointed that I missed it because I was able to get to see this year’s Toronto Criterium (and I’m looking forward to seeing some CycloCross this year), its exciting and fun for a bike race, at least you get to see the riders more than once unlike a stage race.

By the end of August I was back to being capable of pretty much anything but running. Without the physio I didn’t have the strength to support, which is fine by me because it aggravates my left achilles something fierce.

September 10^th actually arrived very quickly, surprisingly fast actually, except for that last three days while I was waiting for the appointment to arrive.

I took the morning since I was fairly certain I’d be low on the priority list to see the surgeon and my appointment was at 10am. I wasn’t too far off, I didn’t get into the examination room until 11:15 and then I waited another 15 minutes before the attending popped in to see me.

Warning - don’t let the attending make decisions about the mechanical fix, always wait for the surgeon!

The attending had the best of intentions, he’d passed by my examination room three times in that 15 minutes and was considerate enough to check in on me, he must have also thought that getting the bed cleared was a good idea because I looked perfectly ambulatory.

He comes in and picks up my chart, reading only the top page he summarizes with “So, you were an Achilles Rupture huh?” and I hit him with it - both barrels: “Nope, an avulsion.”

He looked shocked for maybe a tenth of a second before he turned to the computer to pull up my images. “Avulsion? Wow.” So I explained to him how the diagnostics were mistaken and how my surgeon hadn’t known it was an avulsion until he opened me up. So finally he pulls up my x-rays and looks at them thoughfully “Oh, yeah, minimal bone fragments, that was lucky.”

This is what illustrates that the surgeon is the best person to determine how mechanically sound your fix is. I didn’t have x-rays until after my surgery, he couldn’t have been seeing any bone fragments.

Still he did start the examination and checked the tendon, my strength and my range of motion before my surgeon came in. They exchanged a couple of sentences before my surgeon sat down and eyeballed the tendon while asking about pain, strength and flexion. When the attending mentions that my dorsi-flexion was exceptional the surgeon got a concerned look on his face. Because of this site I knew right away what he was thinking and both the attending and myself blurted out how it was okay, there was no indication of the tendon lengthening.

The surgeon seemed satisfied, signed off on the clinical release and told me I was good to go, just to come see him if there’s a noticeable problem or I need a tune up. He actually took my pronouncement of attempting to find the closest mosh pit and start pogo-ing in stride.

So that’s where that leaves off. I’m now on my own and its a little scary. Probably why I came back to this site and decided to post my experience. Its good to have some people around who understand and will pay attention to your ramblings. Well my ramblings really, everyone else is so succinct its annoying!

May 7^th to June 4^th

Yes I’m changing the span a little, figure if I make each period appropriate to the time between visits to the clinic I can keep it straighter in my head.

So the next four weeks pretty much fly by. In a nutshell I spend less and less time in the boot and more and more time in my sandals.

When I got leave to go FWB I was spending most of my time in the house wandering around barefoot. I figured that was the easiest thing to do. It was certainly a lot less painful than wearing my runners and it let me start building up the stabilizing muscles around the ankle to help with my balance - always a precarious thing.

Basically I was wearing the boot only for traveling on transit or for navigating foreign terrain. I managed to drive a 6 hour return trip during this time and I went to see Nine Inch Nails on the NIN|JA tour - I couldn’t give up the opportunity to finally see Jane’s Addiction and I’ve only missed one NIN show in the past 10 years (their appearance at the Virgin Festival). It was worth the mild discomfort and walking two kilometers in a crowd of 18,000 people.

I bought new, larger, shoes for work to accommodate my slightly larger right foot - which was larger to begin with. I now have feet two distinct sizes different.

I was in either sandals or runners for doing yardwork and occasionally making a trip to the corner store, about 800m round trip, several times. Being crutch free isn’t quite as entertaining on the subway and people find it much easier to ignore you and not give up their seats, but by this time I was just about sick of that. I welcomed the standing and used it for all it was worth to build up my strength. Getting the muscles to profile better, making them stronger, seemed to go a long way to getting the swelling as much under control as could be expected.

I attempted to be as cautious as possible when out in unfamiliar terrain but I was pretty arrogant in familiar areas - luckily it didn’t cost me anything.

There really wasn’t much to tell other than I went through a gradual withdrawal from the boot up to my sixth appointment. I was getting a little anxious though. My surgeon had that habit of looking at me and saying “How old are you? Lets just leave it for another week.” I wanted to be free of the boot for my birthday and barring that I wanted to be free from the boot when I went to a conference in August in Indianapolis. That was my worry, that I wouldn’t be in shape enough by mid-August that I could spend 8 hours a day wandering through exhibit halls or visiting areas of Indy.

I didn’t have to worry though. I saw the surgeon for nearly 3 minutes. He looked as the x-rays, glanced at my scar, felt the profile of the tendon, asked about pain and then told me I was good to go to two shoes.

I was a little numb, I was thinking he would say something about going gradual or something but when asked he simply said if I needed to rest the foot just to put the boot back on if I felt the need - not that I couldn’t have thought of that myself but I’m glad he told me. I asked about cycling and he looked at me as if I were crazy. I qualified my request by saying that I’d only be riding the stationary and I’d start out as easy as I could, he was reluctant but he did agree.

Of course he didn’t know that my stationary bike is a Kinetic trainer built to mimic road riding as closely as an oil based trainer can and that my lowest gear I actually planned on riding was 80 inches. Still I got the go ahead and I nearly pulled the second shoe out of my backpack at that very moment. Instead I waited until I got to the office with my next appointment not until September.

April 24^th to May 7^th

I take pride in my ability to adapt my body to changes. I learned to skate by watching the greatest hockey team ever (The Candiens of the early seventies). I’d watch how they’d kick and slide and imagine myself doing the same, trying to actually feel my muscles perform the actions.

I learned to golf pretty much the same way, ended up with a not too poor swing by watching Niclaus and his ilk.

I learned to swim by watching Bruce Robertson.

Okay, maybe my father had a lot more to do with those things than I typically give him credit for, in fact I may not have tried most of the things I did if he weren’t there.

But I did learn to drive stick by watching NASCAR in the early ’80s!

I do train well through visualization, pick things up naturally. But partial weight bearing?  - DENIED!

I couldn’t for the life of me figure out how to get the timing down, it either felt like I was feathering it or I was simply plopping down on the boot, worse I couldn’t get the crutches to the correct length to handle the transitions. It was a mess.

So I pretty much gave up. I spent pretty much all of 4 days trying to get the whole partial weight bearing thing to happen before I gave up and tried to go to a single crutch, which turned out to be a different fiasco.

I was getting way to much torque on the crutch and I ended up stumbling on it more that walking, so I gave it up too.

So on the 23^rd I crutched back to the office and tried the partial weight bearing thing on the way, it really wasn’t too bad but it didn’t feel like enough and dealing with the wonky sidewalks was bad enough, when I got back to the un-even floors of the office which are disguised by the geometric designs on the carpeting I nearly lost it. I tried again on the 24^th and spent the weekend getting from point to point in the house and even going grocery shopping, but by the middle of the trip through the grocery store my crutches were in the cart.

The next week I spent trying to keep myself on the crutches but I only really had them with me for times when I wanted to go fast or get people out of the way when getting off the subway, or keeping people out of the way when others were getting off the subway (really people - you wait until everyone gets off the train before you try getting on - or you get whacked in the shins by an aluminum crutch)!

Over the course of Week 6 I went from partial weight bearing to carrying my crutches most of the time, that first weekend in May, my second weekend in the boot, I mowed the lawn - the first mow of the season and to top it off I use a reel mower instead of a rotary. It was interesting to say the least. Still it worked out very well and proved that I was well on my way.

By the start of Week 7 I was using the crutches only if I was really tired but I was already noticing that my “Crutch Conditioning” was beginning to wear off. I couldn’t handle the crutches for as long as I had on week 5.  I was down to being able to cover maybe 200m at a time before resting where 10 days earlier I was doing a full kilometer or more without rest.

There wasn’t much pain and the scar has solidified so that there was very little red. I’d get some swelling and occasionally I’d pull a pillow in to bed to help me sleep, but I only tried to sleep with the aircast on for about 3 hours before I gave up on it. Once I had the aircast I slept without weight on my leg and was able to sleep under the covers for the first time in 5 weeks. When I slept with my leg raised I was down to using a single pillow and I would take to boot off as soon as I sat down on the couch.

The second weekend, the weekend I mowed the lawn,  I actually started moving around the house in sock feet. The first couple of times heel walking but it didn’t take long for me to adjust to a more or less regular stride. I had most of my range of motion back so it wasn’t too bad, I just didn’t have any power and if I set my foot down wrong there was considerable pain - so I just didn’t do that.

On May 7^th, the say I was to go back in to the clinic I got up, got my breakfast wandered around, read the paper went down to my home office, fooled around with Assassin’s Creed for a bit, wandered back upstairs had my shower got dressed and then put on my boot. I carried my crutches with me when I left the house, didn’t even use them to get down the porch steps, though I did start using them when I got in sight of the bus stop and kept them in my arms until I got down into the waiting room for the clinic. When they called me in to the ward I carried my crutches with me, say for a while after taking my aircast off while I waited for the surgeon he showed up, glanced at the scar, noted that the holes in my heel had completely disappeared, tested my range of motion (over 80%) and tested my strength (illiciting another ‘whoah’) he then pronounced me good enough to go full weight bearing in the aircast and told me to come back in a month.

Which I did.

Sorry, no pictures…

April 10^th to April 23^rd

So two weeks until the next visit and I manage to get a note that says I can work full time as long as I’m sensible. At least that’s what I ask them to have it say.

Its not a difficult time, I’m getting a little annoyed at not being able to ride and a little annoyed at not being able to drive and a little annoyed at how expensive taxis are and a little annoyed at having to continue to use crutches and a little annoyed with explaining what happened and a little annoyed with the winces and a little annoyed with the sympathy and a little annoyed by the people who so very studiously avoid looking at me when I get on the subway.

But I love how guilty they get when I do make eye contact with them, and I love getting that seat across from them where I can make eye contact at every opportunity and I love the fact that I’ve got two crutches that I can use to block the morons who think that people getting off the subway shouldn’t keep them from getting on the subway. There are many bruised toes over these two weeks!

And its fairly uneventful. Again my wife and I go out to a restaurant for lunch and again we’re sat as far away from the door as possible, but that’s become par for the course, an almost non-event.

I do come across one thing to warn people about - dress pants and aluminum crutches are less than good together. The pockets tend to gape when you’re swinging your crutches forward and of course if it isn’t the butterfly nuts getting caught in them its your thumbs. Nearly ripped my thumbs off a couple of times but that was nothing compared to getting the wing nuts caught and landing right on the ball of the bad foot. That was nearly as painful as the ultrasound.

I also manage to tumble on the subway platform. Every once in a while the subway platforms suffer from seepage. I was always careful around it and this time I was past it, or so I thought, but my right hand crutch shot out from under me and I started to go down, what was interesting is that I managed to take out some woman who was attempting to pass me on the right, despite the fact that I was close enough to a bench to bang my right forearm down on the seat. I don’t know what she was thinking but I hope she woke up long enough to survive the rest of her trip into work, though sometimes not.

I did get a day or two of telecommuting since I tried to avoid taking transit when it was raining, but it was a spring during which it only seemed to rain during work hours. Really annoying when you think about it. Nothing wrong with the day when it starts out, rain during the day making you dread the trip home and then the roads and sidewalks are dry when you leave despite all that worry.

I also get a lot of people telling me their stories. Heavy people with tales about their bad knees, slighter people with tales about compound fractures, older people with war stories and younger people with tales of woe about ingrown toenails. I’m a pretty approachable guy in most cases but I really don’t encourage people to tell me their life stories. I should have started carrying my pictures with me. “See, this is the incision just after my first cast came off…”, probably would have kept them quiet for a time.

The fifth appointment came around just in time to keep me from going insane with all of this, all of it and the promise of getting into an aircast at last. A chance to do a little weight bearing and the first proof that things were actually healing.

Again the visit to the clinic chews up the morning but my boss is pretty understanding about this, he’d gone through some pretty impressive surgery himself two years earlier so he understood. Again I get to joke around with Ricky Gervais who cuts off my cast and the surgeon takes a look at things, cups my foot by the ankle, presses his other hand against the ball of my foot and asks me to push down like I would an accelerator. So I scoot all 6 feet and 200 lbs of surgeon six feet across the floor. Okay it wasn’t quite like that but I surprised him enough that he let out an involuntary ‘whoah!’ when I pressed down with the ball of my foot and did manage to scoot him far enough he had to drag himself back.

He examined the points where the sutures exited my foot, checked the success of the healing on the incision and then compared the flexibility of my feet. I was back up to about 2/3rds of the range of motion I had originally and he said that was good enough for the boot. $150 later I was crutching down the hall all PWB and proud and the orderly told me that the next time he saw me he wanted to see me only using one crutch, and that on the left side.

Well, I had a surprise coming for him.

Pictures

This is how the incision looked as I went into the boot, nicely scabbed and flaky. Yum!

The took the cast off and I got a good look at the progress of the scar along my calf and ankle. I was a little disappointed, there was still quite a bit of redness and the scar tissue looked really shallow, but it was becoming obvious that the gathers that I worried about having to break up during physio were smoothing out all by themselves, certainly helped take a load off my mind!

My heel where you can see the two holes from the traction suture, all nice and clean.

There were just a couple of little scabs left on the bottom of my foot and the skin was already growing overtop, it looked really good underneath and I was no longer worried about the suture trying to crawl back out, by this time it had creeped up and out of the skin and into the meat of my foot.

Slipping into something comfortable and was it ever welcome.

The Aircast. It was most welcome and about 90% of the time it was comfortable, but because my toes peeked out over the end it was possible for me to situate the tongue in such a way that it put pressure right on my cuticles, which I can report is most not comfortable. It was thicker than my fiberglass casts so I was limited to wearing my dress pants or my wind/river cargo pants with the zip off legs. Thankfully April was a warm month.

March 27^th to April 9^th

There wasn’t much going on this week, simply getting things done that I had promised myself I would be able to. Not being allowed to work was liberating and I did manage to get a fair bit done that I had intended. Figured out how to cook as well which was a nice change, even barbecued. As long as I had a chair handy I could stand without the crutches and even move dishes back and forth between the counter and the table. This of course also means I could do dishes.

Once Monday rolled around I was able to go back to work since I had been able to hand in a note from my surgeon. Basically it was worded to say I could work as much as I felt and that I had to elevate my foot and walk around.

I’d gotten pretty good with the crutches to by then, or so I thought. My wife and I decided to meet some friends for lunch, its a pub I like but don’t frequent often and as such I screwed up the directions, getting off the subway nearly two stops too far but I crutched my way back and we had a good time. In all it was probably near to two kilometers, needless to say lunch took a good long while.

Being that we were within walking distance of our friends place we decided to walk back and guess what - it was another 2 kilometers. We stopped often and they were exceptionally patient and even gave me the last beer in the house. We stuck around for a while and chatted, it was pretty good fun and I think it helped considerably in the end. Not only was my conditioning for crutching showing marked improvements but there was significant improvement in my abdominal area, I was getting ripped!

On the bus on the way home a woman who had gotten on at East York General started talking with me, asking about my condition and telling me about her issues with her knees and how things weren’t progressing well. I impressed upon her the excellent service I received at St Mikes and she seemed to think my advice sound. I hope she managed the trip because I think it might have been worth it for her.

I really was getting along quite well with my crutches and as I was returning to work on a near full time basis I needed to make a covering for my toes so as not to offend anyone in the office. I was also lucky in that I was able to fit my dress pants down over the fiberglass cast, though I had to wrap the cast itself in a compression wrap so that the sharpish ends of the fiberglass wouldn’t catch on the fine fabric and rip it to shreds.

I had to get around well because my office was not built to be completely accessible. There were no power assisted doors and the washrooms didn’t have handrails or any other assistive device installed which made figuring out how to handle carrying lunch using crutches and opening doors essential. Luckily the city had yet to implement the mandatory 5 cent fee for plastic bags so most of the time I was able to get lunch to carry away in a bag.

The leg itself felt pretty good. For the first couple of days after my appointment there was a fair amount of tightness in the calf as the tendon and muscle stretched back out. There was also a lot of popping and snapping going on along the incision as scar tissue broke up and started to slide. Sometimes it hurt a little, sometimes it didn’t hurt much more than the original injury but it was neat to feel that pain and figure out how and where it was coming along and just what layer of tissue was giving way.

Finally the Thursday morning appointment rolled around and the cast was removed again, there was little in the way of scabbing left, most of it simply stuck. I picked and peeled scabs while I waited for the surgeon to come through and take a look at his work, even sat there and flexed it a bit, trying to pull the foot into neutral simply on dorsiflexion alone. I even put a little weight on it to see how it felt that way and it wasn’t too bad but it still hurt enough to make me really cautious.

Finally after I had cleaned up as much scab and callous as I could the surgeon came in, I was able to brush the small pile of dead skin and blood onto the floor without anyone noticing. We lifted up the foot, flexed it back and forth under muscle power and with his own hand, the foot actually flexed into neutral and I was able to hold it there without assistance. He poked at the heel and examined my fresh x-rays and determined that this was as good a week as any to take off the button.

Now imagine what I was thinking. This is heavy duty suture he’s put in place and its been in my leg for three weeks. It runs up through the bottom of my heel, through the calcaneous, out and through the Achilles, back down through the calcaneous and back out through the heel. I’d spent much of the previous week trying to imagine what it would feel like to have that suture get pulled out through all of that.

Two little snips later (which actually stung a fair bit) and the surgeon starts to give instructions to the orderly about how to place my foot and cast it. So I asked, first does the suture stay in? Second can I have the button? And yes, the suture stayed in, it wasn’t going to offer any issues and if it started to push its way out they’d cut it back far enough it wouldn’t be able to do that. And yes, I could have the button.

So Ricky Gervais set my foot up as close to neutral as we could manage it and I left the clinic with a nearly flat foot, sutures creeping back into my heel and a button in a bottle.

Yes, I could feel the suture working its way back up through the various layers of dermis and into the deeper tissues of my foot, it was very weird, like there was something burrowing in my leg.

Creepy, but I was more free than I had been in a long time!

Pictures

The incision as it looked on week three just after the cast had come off.

This is what things look like after three weeks. I’ve picked off the loose scabs, the dry skin and most of the callouses. Its jagged, a little angry and scary looking. The gathers are what I fear most, if those don’t absorb in some way they stretching that skin back out would be a painful and terrible day.

A pretty good shot showing the relationship between the button hidden in the surgical sponge and the heel.

This does show the relationship between the button on my heel and the point at which the Achilles mounts to the calcaneous. Right under the deep scar still on my heel is the tendon and the suture pins that hold everything in place. This angle also provides an excellent visual representation of the way the incision was altered after the discovery that the diagnosis was wrong.

What the button looked like fully dressed. The pressure on the sponge was enough to crush the structure - it didn't bounce back.

This is a detail shot of how the button looked before it was removed. The sponge had folded over during the previous application of the cast so I had to hold it out of the way. The pressure on the sponge was so great that it actually crushed the sponge flat and it didn’t return to shape after being release, it had solidified. It wasn’t that much fun having the surgeon pry around under the button to snip the sutures one by one, but nothing moved when he was done!

The heel after spending three weeks in close proximity to a surgical sponge soaked in iodine. Pretty.

My heel is finally naked. Most of the dark splotch is from the iodine that the sponge is soaked in, they gave me a cloth to clean up the foot before they recast me and man did it feel good to wash that down. The two black circles are the holes that the sutures came through, the darkness being scab tissue, you can’t see it but in the middle are the ends of the sutures. Over the course of the next two weeks I could feel those sutures sneak back inside my foot, pulling through the various layers of skin and fat and finally into the meaty bits. I swear I can still feel them move. It creeps a person out I tell you.

This is all that kept my Achilles in place for three weeks, a simple white nylon button.

It really isn’t very much different from the buttons found on surgical scrubs, it creeps me out to think where it might have come from, images of my surgeon completing my surgery with his scrubs puddled around his ankles doesn’t thrill me. Perhaps it was one of the lovely ladies though.

What would I care I was so unconscious I didn’t wake up for a day!

Its not terribly clear but the white bit mid bone are the suture pins.

The white bit near center are the surgical pins. Below the pins, causing the bump in the bottom of the cast, is the button. It still kinda freaky to me to think that’s my foot.

March 20^th to 26^th

Spend the weekend getting used to the hard cast. Its nowhere near as comfortable as the surgical splint, but its also not as bulky or heavy. I actually figure out how to have a jacuzzi, which comes in handy. I’m still using two pillows to sleep but it isn’t quite so uncomfortable as it had been. Spend some of the weekend worrying over how I’m going to get into the office, elect for cabs the first day and then see how things go.

My manager and I organize what times I’m expected and I continue to telecommute to fill out the missing time. It’s amazing how much more work you can get done when you can both remain un-bothered by people and remain in your pajamas. Still its bound to be a bit lonely around the house now that spring break is over so going in will be a good thing.

I do cab in on the Monday and work most of a workday. I do return home a little early because things are just uncomfortable. There isn’t much pain and there isn’t much extra swelling despite having my foot lowered most of the day. I also am required to move around the office a fair bit which definitely helps me keep my spirits up and blood flowing.

I plan on cabbing in on the Tuesday and returning by transit but half-way through the day I get a call from my manager who tells me that Human Resources doesn’t want me in the office because I hadn’t returned a note to them from my surgeon releasing me to work. Great, and not only am I not allowed to be in the office but I’m not allowed to telecommute.

I shouldn’t say much more about this but I will say that things resolved in my favour.

So I cab it home on the tuesday and start trying to arrange things with the surgeon’s assistant, things don’t get very far because of conflicts in hours, broken fax machines, missing numbers. I actually end up with most of another week off.

Wednesday I actually start doing some of the things that I planned on doing but got distracted playing video games. I manage to get nearly a dozen LPs ripped by the end of the week and that feels good. Not only did I do what I told myself I would do but I was able to get fairly far with it.

Thursday I go in for my second post operative consult with my surgeon and this time I remember my camera. Again I get into the clinic a little early and again I’m out of the clinic about 2 hours later with another cast. This time they actually reduce the plantar flexion to about 45 degrees. It causes some pain and a little pulling but feels good until the cramps hit after I go to bed. Still not too bad an exercise. The surgeon has the stitches removed and reviews the wound and examines the penetrating sutures for signs of necrosis but seems satisfied, perhaps even surprised.

This is also the first chance I get to both scratch and wash the foot, and that feels good, especially with all of the callouses starting to fall off.

A new cast goes on and the surgeon asks about my Percocet situation, I report that I’d pretty much stopped taking it and that I was about half-way through the APO, then I complained about the taste and got a look that basically conveyed the entire “you take it because it’s keeping you healthy” argument.

Crutch back out and this time actually take transit home, makes for an interesting experience, I’m the only person on the train wearing a cast and the only person on the train in shorts. Wasn’t too bad really.

Pictures

A little sticky around the sutures

Its not a great picture, but it does show the extent of the incision and what everything gathered up like. I was a little worried about that, that it may create some ugliness when it came time to start stretching things out, but that never happened.

There was a little seepage, but nothing special.

There was a little seepage right at the crest of the heel, which is understandable be cause under that point is whipped stitched sutures, suture pins and a traction suture, not to mention the swelling that comes with the territory of having to have your skin cut apart by scalpels and holes drilled through your bones. But at two weeks its looking as good as I hoped and though there is very little movement at least there is some.

This is the button keeping my achilles in traction.

That’s what a button will get you. When my wife first saw it when I brought it home in a specimen bottle after it was removed, she said she could imagine the surgeon standing at the foot of the bed at a loss looking around for something to help hold the sutures outside of my foot then settling on removing the button from his scrubs. I don’t think that would have happened, he would have someone else remove it so he remains sterile!

Its a simple nylon button, but it seems to have done the trick!

Cheating the First Week

March 13^th to 19^th

So I’m counting my first week from Saturday to Thursday and that happens to be because all of my appointments for checkups and inspections were on Thursdays. Cheat #1

It was spring break, which didn’t mean much for me I was still missing work but it meant my wife (who of course happens to be a teacher) had the week off, sucks for her but it worked out well for me. Cheat #2

It was a dreary cold spring and every day I stayed inside, it rained, every day I went out it didn’t. Cheat #3

What probably counts more is that I suffered very little pain in my leg, though my chest, arms and abs were burning, crutches suck for the first two weeks. The Percocet remained relatively untouched and like the morphine and the Tylenol 3 before, didn’t do anything for my pain. They did provide some minor relief from swelling and their side effects thankfully counterbalanced the side affects from the antibiotics (which tasted a lot like cat urine smelled).

I was in a surgical splint with my foot in a full plantar flexion, the toes almost complete en-pointe. Still it wasn’t that uncomfortable and with my body geared up to repair itself and the insulation that I got from all of the cotton in the splint I didn’t need to worry about my foot getting cold when I did go outside.

My original plan had been to only take a couple of days off from work, but then I was informed of the presence of our short term disability plan and saved myself some vacation. While I was not-sleeping in the hospital I had come up with all kind of plans for what I would do with that time off. I could telecommute so I could work from home but I could also get a handle on ripping my LPs, perhaps get the bulk of them done. I spent about 100 hours playing stalker instead.

When we came home on the Saturday we opened up the pullout couch and sat down with take-out in front of the TV and watched movies, sleeping in the living room, nice and relaxing. The worst part of course was going to the bathroom, it really isn’t that easy to sit on the toilet when you’ve only got one good foot. I eventually got around to learning the trick about kneeling on a chair.

Sunday night I slept in my own bed. As I said before I’m a stomach sleeper so it became necessary to figure out something. I needed to keep the foot elevated at night because the pulsing of the wound kept me awake but I found that two pillows supported the leg nicely, when I woke up Monday morning the splint was actually loose enough I worried about it falling off. Not that that lasted for long but it gave me some hope that things were going well.

One thing about sleeping with two pillows under your foot, its really hard to do under the covers. I ended up sleeping in my dressing gown and wearing a sock. Kept me from getting too cold anyway and it wasn’t until my second cast that I was able to sleep comfortably under the covers with just a single pillow.

Monday was a lot of the same as usual, just a little more challenging. Get up, have breakfast, watch a little television (I got hooked on Boston Commons), have lunch and then mosey downstairs (sliding on my butt of course) to log in and do a little work and then slip into a game for a while. Have some supper, watch some TV, do some email and go to bed. It all started to get easy too as I repeated that Tuesday and Wednesday.

Thursday I had to get up early. This was the day when it became clear that Percocet actually does have an affect on me, it makes me cranky but by then I’d brought myself down to two a day. But I was a bit of a bear to be sure.

Still the cab came quickly enough that we had an extra half-hour worth of wait time at the fracture clinic. Still it was pretty quick and when we went in the cut off the splint letting me see for the first time what it was they had done.

And I’d forgotten my camera again.

There was still some seepage from the wound but it had scabbed over nicely. The wound itself was puckered together like a six year old had been trying to learn how to do gathers at the sewing machine ( yes I do personally know what that looks like - I gave up sewing early in life). Still it looked good and I gave my foot a couple of experimental twitches to see what it felt like. That set off an involuntary stretch which really didn’t feel all that good, and triggered a muscle memory based flick which hurt - well it hurt a lot.

Dr Whelan came in, examined the incision and the sutures, took a look at the penetrations for the button, threw some disinfectant on the wound and then told the attendants to put me in a hard cast.

Just before he left he said everything looked just fine.

Nearly Awake

I’d heard the day nurse tell the night nurse that the doctors would be making rounds about 6:30 and when I awoke yet again at 5:30 I stayed awake hoping to catch them and hear what my complication was.

I had a decent breakfast of scrambled eggs, juice, toast, fruit and milk and waited longer.

The night nurse changed to the day nurse and I waited longer

Eventually my wife came in and we talked about what the complication might have been, deciding that we’d stick around until we were able to see someone about what had gone on, so I waited longer.

The day nurse came in to get some numbers from the pump and see how things were going so we had a talk with him about finding out what was going on, he went off to make some calls and I waited longer.

Lunch came, macaroni and cheese and I think it was the Velveeta kind, still it was hot and not too bad. But I still had to wait.

About Noon Dr Whelan himself came in and sat down asked if we had any questions and then explains.

The Surgery (from the point of view of someone awake at the time)

They opened me up with the typical off center incision they use about 6cm up from the calcaneous. As soon as Dr Whelan had opened the sheath he knew he wasn’t seeing a rupture because he was looking at the end of my Achilles, I’d suffered was is called an Avulsion.

An avulsion is a parting of the ways, literally. Unlike a rupture the tendon itself remains intact but it pulls off the bone that its attached to. In many cases the avulsion is the result of a fracturing of the bone its attached to and the tendon actually pulls part of the bone with it. Because of the porous nature of the calcaneous it is prone to this injury. When this happens the injury is called an Avulsion Fracture and requires a debridement of the mount point or even that the tendon be attached to another like the Achilles to the Flexor Hallicus or somesuch.

What this meant is that Dr Whelan continued the surgery but reworked it to be very much like the surgery that is involved in dealing with a Haglund’s Deformity.

They whip stitched the tendon to provide some extra stability, drilled two holes through my calcaneous and out my heel, dropped thick sutures through the whip stitching and out through my heel, mounted two suture pins in the calcaneous on either side of the tendon, pulled the tendon tight with the heel sutures, sutured through the tendon and suture pins and then tied off the heel suture against the outside of my foot.

I ended up with a penetrating suture tied off to a button on the bottom of my foot and two extra pins. The goal was to get the tendon to heal back onto the calcaneous and because the calcaneous is weak under specific tension like that the tendon had to be put into traction. They  rested my foot in extreme plantar flexion and put me in a surgical splint.

Dr Whelan predicted that my recovery time shouldn’t be much longer than with a regular Achilles rupture and then said I could go home, with all the caveats that entailed. Keep it elevated, don’t get it wet, take your antibiotics and don’t forget your percocet.

And no, Ontario has not approved Vicodin.