5 Months Post-OP

Posted on August 17th, 2018 by Darren

Since I last updated my original April 2017 post I was finally scheduled for reconstruction surgery in March 2018.  If you don’t want to read the saga of how I got to this point, the short version is I fully ruptured my left AT in September 2012 at 42 years of age playing baseball.  My first OS only recommends a non-surgical protocol, which I followed.  After 3 years of left achilles/foot and right hip pain the same OS told me I would just have to be inactive for the rest of my life.  I was finally recommended to the top foot/ankle clinic in BC (Canada) and they discovered my achilles had healed much too long (about 1″).

The 6 months prior to surgery I led a very sedentary life aside from coaching hockey.  This meant less pain in the leg and opposite hip, but being inactive was not how I wanted to live.  When my former OS told me a few years ago I was just going to have to be less active, I suppose he was right…but it’s ridiculous to be told to be sedentary at age 45!

Prior to surgery my OS told me there’s a 70% chance my AT will improve, 20% chance it will stay the same, and 10% chance it could get worse than it is now.  A year ago I would have jumped to do the surgery if there was a 20% chance at improvement, but being less active certainly reduced the aggravation of the bad tendon.  I know the right answer was to get it done with the goal of being able to lead a more active and healthy lifestyle again, especially for my family, but the lazy, popcorn-eating, beer & Bacardi-drinking, TV watching side of me didn’t mind continuing this way.  :-)

I read and watched everything I could find on the internet about achilles reconstruction surgery.  It’s surprising how little information there is online about the procedure I was going to have called ‘Z-Shortening’.  Effectively it’s a way to shorten the achilles without completely severing it straight across.  They were also going to clean up any degenerative (bad) tissue from the original injury 5.5 years ago.

March 15th was the big day.  I was given a nerve block in my leg prior to surgery to block the pain after the surgery, which is a wonderful idea…but more on this shortly. I was wheeled into the OR and 2+ hours later I woke up with a big dressing and cast on my leg and dreaming about accounting theory!?!?!  The nurse must have thought I was a real exciting guy telling her all about it still half out of my mind.

The first few weeks were fairly standard stuff I would think.  Sutures removed after 3 weeks and weight-bearing as tolerated.  OH!  I highly recommend getting a knee scooter for around the house and in an office environment.  They are such an improvement on crutches!  I was coaching baseball all Spring and even got an all-terrain version that kept me mobile outdoors.  The healing process, weight-bearing and strengthening have been fine and I seem much further ahead of the non-operative timeline I experienced.

Once I had the dressings and stitches removed I finally realized numerous places on my foot were completely numb.  3 outside toes, all along the outside of my foot, in the arch of my foot, and all up the heel to the top of the incision.  The incision area being numb is totally understandable, but the toes and foot were a concern.  My OS figured the nerve block might be the cause given the nerve damage seems to be beyond the sural nerve area.  I was told to give it some time and after 4 months I should see improvement.  At the 4 month post-op appointment the OS changed his tune somewhat and said to give it 6 to 8 months and he thought there might be some sural nerve damage from the surgery.  What’s getting me concerned is instead of getting better after 5 months it actually seems to be getting worse.  More numbness in new areas of the foot and even less sensitivity on the side and underside of foot.  If anyone has any experience with nerve damage post surgery I’d love to hear about it!

As for the achilles and recovery, it’s a slow process but I can see marked improvement in functionality compared to before the surgery.  I have learned how much my body was compensating for the lengthened AT before the surgery and how much this affected my gait.  I had to learn how to properly walk again (heel-toe, heel-toe, heel-toe) and as a result all hip pain is gone!  I have an enormous amount of physio to do as I’ve essentially got a calf and toes that have not been used properly for almost 6 years.  I’ve got an excellent physiotherapist and hoping 6-12 months of PT will get the calf back.  I’m not happy with the nerve damage, but considering the functionality I’ve gained so far I would do the surgery again.  Hopefully I get some feeling back in my foot eventually and hopefully I can get the muscles back enough to do a 1 leg heel raise or climb a ladder or even go for a run.

If I could give anyone advice who have recently had an ATR:

  • If your OS recommends conservative treatment, get a second opinion.  In my opinion, conservative treatment should be for people who have too high a risk for surgery or have no plans to play even recreational sports again.  If you don’t plan on being overly active, try the conservative approach.
  • If you choose the conservative method, cautiously weight-bare as early as possible.  I think I was immobile far too long the first time around.
  • Get a knee scooter!  Crutches suck.
  • Find a good physiotherapist and do the work!!  Try to find a physiotherapist that allows unsupervised time so you can work out longer.  You need to work hard to get that muscle strength back.  Start strengthening all your leg muscles as soon as possible without stretching the AT.
  • Get proper gait training!  Take short steps to start and remember ‘heel-toe, heel-toe’.  Don’t let your body compensate for weak muscles or pain.  Use crutches longer or get a cane if you have to, but don’t let other parts of your body compensate for your healing leg.  The body is amazing at compensating, but that leg needs to learn how to use the muscles and tendon again.  If you have pain elsewhere you’re either trying to do things too soon or there is something wrong.
  • Have your OS ensure the tendon is the proper length.  I’ve read in medical studies how conservative treatment seems to result in tendon lengthening and trust me, you don’t want this!
  • Be patient.  This injury is life-altering for at least a year.  I remember the first time that it was 18-24 months before the tendon stopped improving.  Work hard, but you have to realize it’s going to be a long time to get better.

Good luck to all.  I’d love to hear from anyone who’s had a Z-Shortening procedure to see how they are doing and would really like to hear about anyone’s experiences with nerve damage from the surgery or the nerve-block.

Thanks for reading!

Darren

2 Comments »

4.5 Years & Counting

Posted on April 22nd, 2017 by Darren

April 2017

Thankfully the MRI results proved my left achilles that ruptured 5 baseball seasons ago healed poorly.  My orthopaedic surgeon (OS) described it to me as the tendon healing in a very disorganized manner and agreed with me that it healed long. The MRI report stated prominent fusiform enlargement and intrasubstance mucoid degeneration.  Surgery to fix the tendon was the best solution.

Yes, I meant to say thankfully.  I’m not crazy and there is renewed hope.

A Medical Mulligan

So after 4 and a half years of pain, doctors, MRI’s, steroid injections, and physiotherapy I have decided to tell my achilles rupture story.  I hope to provide a unique perspective on the surgery vs. conservative treatment debate and then give updates on my status once I restart the entire process.

Unfortunately after 4.5 years I have been told I need to start over.  If I want to have a better quality of life, attain more functionality, and live with less pain and swelling, I must give the medical community a mulligan and try again.  In 2012 I was advised that a non-surgical approach for an ATR was the new standard in treatment. In 2017 I am now told I need to have surgery to fix what did not heal properly after conservative treatment. To some extent I want to tell my story on here because 4 and a half years ago I came to this website looking for answers and advice and maybe if I had read a story like mine I would have chosen a different path.

Before I have the anti-surgery crowd criticize me for potentially impacting the decision of a new ATR victim, I say up front that my particular experience is likely not the norm.  There has to be others like me out there, however and people should be aware of the possible negative outcomes of the conservative approach.  Much of what one reads online seems to say that conservative and surgical treatments have similar results.  Well, that has not been my experience.

I apologize in advance for the length of this first post, but 54 months is a long time to catch up on.  Hopefully those of you who read it find it informative.

Rounding 3rd Base

September 6th, 2012.  Was it really that long ago?  I was playing baseball during the lunch hour in Montreal.  I live in the Vancouver, BC area, but worked in Montreal often.  Being I travelled so much I did not get to play sports like I once did and had been looking forward to getting on the field.  My first at bat and I hit a long ball to right centre field.  My 42 year old body darted out of the batters box and ran hard around the bases albeit not near as swiftly or as athletically as I once did.  As I was rounding 3rd base I noticed the ball was coming back in from the outfield so I instinctively put it in a higher gear to make it home safely…when it happened.

I heard and felt the snap in my head before I tumbled in full flight to the ground.  I turned my head around and accusingly asked the 3rd basemen if he hit me.  Of course he hadn’t, but it’s the classic instinctive reaction you hear about.  I actually knew my achilles was gone.  I’ve watched and played enough sports to know and I’ve heard stories from friends and teammates who ruptured theirs or who had seen one happen.  I started feeling pain, but it was from my shin and knee where the ground had torn up my skin when my left leg gave out and drove itself into the ground.  I was helped back to the bench disappointed that I never did make it to home plate!

Montreal - Worst Hospital Care in Canada?

I was hauled off to the ER of a local hospital by my work colleagues.  They were debating the whole way which hospital to take me to since the wait times in Montreal are notorious for being incredibly long and as an anglophone they didn’t want to take me to a French hospital.  Surely something like this though wouldn’t take too long to get looked at I remember thinking.  It was around 1:30 pm when I got to the ER that Thursday.  I sat in the waiting room bleeding all over the place and writhing in pain from the spasms in the back of my leg until 9:45 pm.  Once I was finally seen by a doctor I told him about hearing and feeling the snap.  He told me he believed I just tore a calf muscle since that’s the area where most of the pain was and that I should go home and give it a few days of rest.  He would get an orthopaedic surgeon to contact me and see me in a few days just to make sure.  I’m still waiting for that call, by the way.   He asked a nurse to clean and bandage my knee and shin.  I asked if I could get some crutches and was scoffed at for such a request.  He didn’t think I needed them.  I insisted and once the nurse "cleaned" my wounds I was sold a pair of crutches.

Back home in White Rock

After a painful night full of leg spasms I booked the first flight available back home.  I knew something was wrong with my leg and wanted to get back to ‘civilization’ (with all respect to my Montreal friends}.  I went to the Peace Arch hospital in White Rock shortly after getting home and was seen by a doctor in the ER within 20 minutes.  After less than 1 minute of examination, he told me my achilles was completely gone and that he would get me in to see an orthopaedic surgeon early the next week.  He also asked the nurse to clean up my leg as there was still gravel and dirt in the wounds!  They had to topically freeze my leg in order to scrub everything out and then bandaged it up.  Nice job Montreal nurse!  I was told the wounds were fairly severe and that I would need to keep fresh dressings on for a couple weeks.  To be honest the pain from the superficial wounds on the front of my leg was more severe than the actual achilles rupture.  The wounds took about 2 weeks before some form of skin/scab formed and before the pain subsided.  I was sent home in a standard aircast in a neutral position until I could see the OS.

The Orthopaedic Surgeon…How Ironical

It was a few days before I got into the OS office.  I met the young OS and nearly laughed out loud at the irony…he was a new doctor that was getting some experience in BC until he returned back home to…..Montreal!

He told me he was pretty sure the achilles was fully ruptured and that I had a decision to make: either to have surgery or to treat the rupture conservatively.  The catch was that the OS practice I was sent to no longer treated any achilles rupture surgically.  If I wanted that option I would have to be referred to a different office.  To the young doctor’s credit, he said he was not in agreement with this policy and said that if he were back home they would likely do surgery.  I was sold a pin cam walking boot and was told that regardless of my decision that I would eventually need this boot as part of the recovery process .  I was sent to get an ultrasound done and was to return back the OS office in about a week to inform them of my decision.

Surgery vs. Conservative Approach

If you are reading this and have to choose between having surgery or not to repair your rupture I honestly pity you.  It is an extremely difficult decision to make, especially if you have no life-threatening reason to avoid surgery. While no longer any sort of athlete and definitely not in the best shape of my life, I had no medical reason to sway myself away from surgery.  I worked in an office environment, which I partially think the medical community views as being disadvantaged from a health perspective and certainly not urgently requiring surgery in order to return to work.  I never heard once from anyone that a 42 year old recreational athlete and coach should have surgery…but maybe they should?

I must have spent 3 straight days reading everything I could find online about ATR’s, especially about the conservative method and early weight-bearing.  To this day I still hold an unwarranted grudge against the medical community for not having a more definitive treatment protocol.  Why should it be left to the patient to decide, isn’t that what doctors are for?  I ended up getting 3 opinions from doctors on what they would do:  the official opinion from my assigned OS and 2 informal opinions from other doctors .  It was 2-1 in favour of the conservative approach and I ultimately chose that path.

Dr. X’s Protocol

I won’t mention the doctors name here, but after 4+ years of lost time I would not recommend him.  The young OS from Montreal followed this mentor’s protocol for conservative treatment as follows:

  • Pin Cam Boot for 12 weeks+
  • Starting at maximum plantar flexion for 6 weeks and then every week increased dorsiflexion until neutral
  • Partial and full weight bearing once the boot was neutral enough to put weight on it.
  • Physiotherapy started at 12 weeks

I’m sure this seemingly late weight-bearing protocol played some part in my poor healing process. Who knows how much though.

On the Mend

After about 4-5 months post-ATR I did see improvement and was able to walk adequately.  Another work colleague (around the same age) ruptured his achilles about 3 weeks after I did and had surgery.  I recall his recovery time was much faster than mine as he was walking and skating well before I was.  Still, I was not too concerned about my progress at this point.  I did notice that I started getting pain in my right hip, but the doctor and I attributed this to the opposite side hip compensating for the weak ATR leg and the slight limp that remained. This should dissipate in short order I believed.  Physiotherapy was stopped when I was told there wasn’t much more to be done from her point of view. More on this later.

After about 6 months the pain in my right hip intensified to the point of being a nuisance.  The OS eventually suggested a steroid injection in the hip, which did help for a few months.  The achilles was still weak but it seemed to slowly improve and harden as time went by.  It was also noticeably thicker than the other tendon, but this was also expected.

1-2 Years Post-ATR

After about a year I still couldn’t do a one-leg heel raise and couldn’t run.  I just couldn’t push off well enough.  When I walked any more than a few blocks or had to walk across an airport terminal I would be in pain later that evening and more so the next day both in my achilles and my hip.  My achilles was harder but still didn’t feel healed yet. I was given another cortisone injection in my hip AND one in my achilles for the pain. Like before, the injections seemed to help with the pain for a few months, but eventually wore off.

I believe my achilles had reached it’s maximum recovery stage at about 24 months.  It was around this time that I didn’t notice any further improvement in strength or hardness.  I still couldn’t achieve a full heel raise and couldn’t run any great distance.  I tried playing sports a few times but it was never near the same as prior to the injury.  I kind of resolved myself to the fact that this was as good as it was going to get.

3-4 Years Post-Injury

The hip pain intensified month after month.  Even after further injections the pain would come back quicker and with more intensity.  If I happened to roll on my side when I slept I would be awakened to the feeling like my hip was on fire.  My achilles would also ache and become swollen whenever I got some sort of exercise using my legs. The only time my hip or achilles didn’t actually hurt was when I just didn’t move. I was sent for an MRI on my hip and the results came back as a degenerative tendon.  Another tendon issue?!  Surely this had to be somehow related to my achilles considering I never had any hip issue until the rupture.

My OS told me that based on the hip MRI results that I just couldn’t be active anymore.  I was told there are developing techniques where blood is injected into the tendon to try to regenerate it, but the effectiveness is really not proven yet. My best bet to avoid pain in my hip and achilles was to be sedentary.  When I suggested the hip pain is a result of the achilles not being right he just said there is nothing that can be done about either. I was 46 years old when I was told this.  46!  I decided I needed to get another opinion. I am fortunate to have an aunt who is an MRI radiologist.  She asked a doctor where to go for help and he said the "FAST Clinic" in Vancouver that specializes in foot and ankle issues.

The Foot and Ankle Specialist

Seven months after getting a referral I finally got into the FAST clinic…more irony.  The OS was quite surprised at several things:  the weakness of my left leg (calf and achilles), the size of the tendon, the size of the large bump where the rupture presumably occurred, and the swelling of the area.  He ordered an MRI and asked me to go for physiotherapy to try and work on the strength of the calf then come back in 6 to 8 weeks.

An Excellent Physiotherapist

Thanks to Google, I found a local physiotherapy clinic that had several very good reviews.  I wanted to try someone different than last time and I really lucked out with this decision.  The gentleman that worked with me is excellent and proved to me how mediocre the physiotherapy I had following the ATR was.  My left calf was 1 inch diameter smaller than its counterpart and my right hip was extremely weak as well.  I’m not trying to blame the previous therapist, the reality is that everything is weak from 4 years of achilles problems.  My physiotherapist proved to me in short order that the achilles healed long.  When doing dual heel drops on a declining leg press machine, my right calf felt like it was going to burst, yet my left calf was under no strain at all.  He told me that he can really help me with the hip and calf strength, but only up to a certain point since he just couldn’t help with achilles.

Now that I have experienced some excellent physiotherapy, I cannot stress enough how important it is to find someone that really knows what they are doing and to work hard at this stage of recovery.  My guy charges a flat fee per session no matter how long you are there for.  I would spend 2 hours at the clinic on the exercises with him working directly with me on and off for about 40 minutes. I find this method so productive.

The MRI Results

I went back to the foot and ankle clinic 2 months later with a stronger leg and hip, but the pain and swelling was even more prevalent, especially in my achilles.  The MRI results showed the achilles did not heal properly.  Disorganized, degenerative tissue and a 1 inch x 1 inch bump at the rupture site.  I had 3 options:  continue living with what I have now, an annoying brace that I would likely need indefinitely, or surgery, with the latter being his recommendation.  It was a surprisingly emotional response that overcame me when I heard this.  For one, I was expecting the OS to say there was nothing they could do and secondly, there was a moment of redemption in that I knew something was wrong and just needed to find the right person to confirm it and do something about it.  I didn’t hesitate in accepting the surgical option despite it meaning my loved ones and I would have to go through the entire healing process all over again.

Hope

I think this is what I want people to understand and hopefully appreciate.  That the poor result I received from the conservative treatment was so inadequate that I am willing to subject myself to starting this journey all over again in hopes of a more functional limb and a better quality of life.  Again, I’m not saying the conservative approach is bad for all, nor do I claim that my results are typical.  I do claim, however to be a proponent of being informed and aware of all the possibilities when having to choose between having ATR repair surgery or not.  Poor results like mine are a possibility and I really didn’t consider this when I had to make the decision the first time.

If you read this far, thank you!  It is therapeutic to the mind to regurgitate the journey so far.  I don’t have a surgery date yet…a few months I am expecting.  I look forward to any comments and to hear others’ experiences as well and hope to continue posting occasionally as this process continues.

** UPDATE **  I just learned today that surgery wait time is 9 to 12 months.  For as grateful as I am for all we have in Canada, waiting another year to have this correctly is ridiculous and embarrassing.  It is so deflating when I found out how long it would be, especially considering the renewed hope I had that there was hope of it being fixed soon.

8 Comments »

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  • Recent Comments

  • cserpent | August 18th, 2018 | 2:44 pm

    I’m 1.5 years out and still have some numbness on my heel. There is less numbness there then initially so some numbness does go away. My doc said there may be some numbness that is permanent. So the remaining numbness in my heel may be permanent. I do keep massaging it in order to give it some stimulation since I do know that nerves can regrown.

  • shell37 | August 17th, 2018 | 9:47 pm

    Good to hear you seem to be having success this time around, Darren. My story is complicated, so I won’t bore you with too many details. I didn’t have an ATR, but a Haglund’s deformity removal and Achilles reconstruction, after a posterior arthroscopy to remove an OS trigonum (floating piece of bone) and FHL tendon repair. My Haglund’s surgery was March 2017. In October 2017 while working to try to break up scar tissue I developed nerve issues - numbness and tingling in the sole of my foot through my heel, down to my big toe, and along the outside of my foot to my baby toe. Felt like my foot was asleep ALL the time. They told me it was a sensory nerve issue, not a functional nerve issue. So feels funny, but doesn’t effect function. It lasted 5 or 6 months, then eased completely, other than occasional tingling. I had had no more nerve issues until the last few weeks where I’ve had a little bit of on and off tingling again, and notice my foot falling asleep kind of spontaneously for no good reason. But again - it’s just sensory - ie. not a big deal (for the people not wearing the foot!!). As I said, my story is complicated

  • Darren | February 22nd, 2018 | 4:14 pm

    Hi atr2011! Apologies for not replying to your comment…I received no notification. Thank you for sharing your similar story to mine.

    I have sent you an email and will post a comment on your blog. Hope you’re healing well!

    [WORDPRESS HASHCASH] The poster sent us ‘0 which is not a hashcash value.

  • atr2011 | June 24th, 2017 | 5:41 am

    Darren,
    I feel your pain. I to have a similar story to yours. I just started a blog here too. I completely rupture my achilles in Sept. 2011 doing Taekewondo. I was 42 years old at the time and a very active female. Conservative healing was highly recommended by the OS. Trusting the surgeon since I was at one of the best clinics in Southwestern Ontario, I took his recommendation and did a whole year of PT at their clinic in London with the PT that helped write the paper on conservative healing. Long story short after 8 months of PT, 1/week in London, Ontario. I felt my results were not a desirable one and would question my recovery to the PT. He would get annoyed with me and say it just takes time and I will be fine. Well here I am 6 years of physio and chiropractor visits, not to mention dealing with the mental stress of not having your physical strength and dealing with the pain that comes with all of this. I pushed forward to see another OS at the same clinic. This process was lengthy on wait times. It took 2.5 years (started in 2014) total from first referral to surgery. Once I did see the new OS with an MRI, he l

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  • ericbabula | April 26th, 2017 | 12:34 pm

    WHAT???? 9-12 months??? Yikes! Wow, Darren - that really stinks! Maybe you wanna look around, like shell said, at smaller markets. Or, come to Wisconsin and have it done in a few weeks! :) Of course, you’ll pay through the nose, but at least it’ll be done!

    Sorry you didn’t get better news.

  • shell37 | April 25th, 2017 | 10:52 pm

    Oh wow. That’s a long time. I know the wait times here in Southern Ontario for things like knee & hip replacements can be 1-2 years. It’s terrible. Could you have it done in a smaller market? Lots of times here, smaller hospitals don’t have the wait times. I waited 3.5 months for my surgery and that seemed torturously long. I’m sorry you didn’t get better news.

  • Darren | April 25th, 2017 | 6:42 pm

    ** UPDATE ** I just learned today that surgery wait time is 9 to 12 months. For as grateful as I am for all we have in Canada, waiting another year to have this correctly is ridiculous and embarrassing. It is so deflating when I found out how long it would be, especially considering the renewed hope I had that there was hope of it being fixed soon.

    Thanks for all the previous comments.

  • pjhalifax | April 22nd, 2017 | 12:15 pm

    I read your story and really admire your persistence in the face of medical professionals putting up so many walls. That’s what it looks like to me, at least, and I wish you the best in the next phases of recovery. Even if it takes a little while to get the surgery performed, at least you’ll have that feeling of vindication and hope for a more complete recovery to buoy your spirits. Definitely keep us up to date here on the blog…

  • ericbabula | April 22nd, 2017 | 9:52 am

    Hey Darren. First of all, I feel so bad for you that you had to endure such pain and incompetence for these past years. That sounds just awful!

    I, too, ruptured my left AT in 2012, but back in Feb. of that year. So, by the time you got on achillesblog.com, I was probably not on it much, anymore. Given that I really wanted to continue playing sports, volleyball in particular, I selected the surgery route. At that time, my OS believed the results to be stronger, with a lower chance of rerupture. So, I was all in. All went well for me, and I have been pretty darn good, playing vball year-round…….until April 1, 2017, when I ruptured my right AT the same way I did my left, playing vball!

    This time, I couldn’t go the surgical route, even though I wanted to. I had a heart attack back on Nov. 30, 2016 (at only 49 1/2 years old), so the Anesthesiologists wouldn’t let me have surgery - too high of a risk to have a heart attack on the table. So, I’m forced to go the non-surgery route this time. Of course, I had to read a bunch of studies, etc., and it appears that with the new protocols, the success rate of non-op route is almost as

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  • shell37 | April 22nd, 2017 | 9:35 am

    I read your whole story. I agree, just telling the tale can be very therapeutic. I am at 4 weeks post op from Achilles surgery that was nessecitated due to a previous surgery that I was promised would solve all my problems. Although, my first surgery was only one year ago, so my timeline is much shorter than yours. So I totally get the emotional roller coaster of the prospect of starting all over again.
    It sounds like your care the first time around was inadequate, to say the least. My OS is a leading researcher on the conservative approach to ATR healing, but stresses the huge importance of early weight bearing. I do find our health care system (also Canadian) to be very frustrating, in that the wait times are long, and you never really know if you’re being treated by someone who really knows what they’re doing and is up to date on all the latest findings.
    It sounds like you’re on the right track now and in good care. I’m also in my mid 40’s and I justified having ANOTHER surgery, and starting all over again, as (hopefully only) one more year of dealing with this, or living the next 40 years in pain. It seemed like an e

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