Archive for May, 2014

May 21 2014

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goldman

nine weeks The Leg awakens

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Nine weeks post-op.
Driving.
Walking.

The past two weeks have been somewhat interesting as I endeavor to transition out of the boot. At week seven I was to begin going two-shoes. Somewhat petrified I tentatively took a few steps. Being busy at work with software deadlines and not wanting to get too distracted and re-injure myself, or worse, fall down one of my two precarious flights of stairs at home and break something new e.g. the good leg, I stuck mostly to the boot. At week eight I called my OS’s office to complain that they were refusing me PT for no damn good reason, and to ask where I should be shoe-wise.

Nurse Betty (name changed to protect the innocent) instructed me that I should aim to be boot-free in two weeks, which puts that one-week from today. I took that advice to heart and have slowly been increasing my daily hours to the point that I am about 70% out of the boot, and even went for a walk into Colonial Liquors after work tonight. My goal was to enter boot free, buy a fifth of gin & a cigar, chug the gin, and walk back to the car without falling over to enjoy a nice rich victory stogie. I cheated and parked in the handicap spot, otherwise smooth sailing.

Nurse Betty also told me that I could get a prescription for PT. Finally. WTF? Why I was made to wait until (a) I called, (b) 8 weeks post-op is a mystery to me. But I jumped right on that; However due to time delays of one sort or another, early morning International Space Station orbit sightings or some such nonsense, I did not get my first, yes my first at nine weeks frigg’n post-op PT appointment set up until next week. Thank the Lord almighty for this web site because it has guided me thru the dark times.

Today at work I shocked a few people by emulating Homo erectus. I had to stand absolutely still, but it felt greeaaat to stretch the calf and groin muscles and gain about two inches in height from my usual injured stoop. I had a sh*t eating grin at one point and one of my co-workers, who is absolutely completely distracted with her own situation of being back at work four months after giving birth, looked at me and said: “Hey, no boot!?”. But really she was thinking: “You are such a pu**y. I pushed a human being out of my body. Try that and walk normal.”

On the exercise front I have been slacking off on all the week 4-8 exercises due to 2-shoes. My daily routine up until last week had been:
- core: plank
- core: Dragon Flag Advanced Core Exercise Credited to Bruce Lee
- 20 to 100 situps
- exercise bike - some boot, some non boot
- toe swirls and ankle flexions - many times a day, not just the three that the MGH protocol recommends
- hip abductions and hamstring curls
- a few pushups
- 12′ pole vaults
- chicken fights on wife’s back and defeating the next door neighbor couple two-out-of-three match

I was joking about the Bruce Lee and pole vault stunts.

Now I need to re-tool a bit and since I won’t be getting any PT feedback for a whole week, will rely on blogs on this site for some guidance. For example if not too swamped by work, I may try to make it over to the local high school pool a la Smick.

Over the weekend I developed my own form of calf raises against the wall sitting down and facing it. I just did a search on achillesblog.com and seems that others came up with or were instructed on same.

I have been boot free in bed for a week or more. Yesterday I woke up after getting a rare 5 hours straight sleep. For a second or two I could not remember which side I had injured. Another milestone!

Driving continues to challenge me. I thought by now that it would be 2nd nature. I have dramatically increased my average speed, but I still use the emergency hand brake a lot. I still dread going over bumps that agravate my sore heel, and stick to the back roads most of the way back and forth.

Regardless of complaining and the aggravation of the lack of PT prescription, I consider all of the above positives. On the negative side I am in pain a lot - most of my lower body: the heel, calf, groin, left foot which seems to sympathize with the right, back aches, and headaches. At least the tendons on both legs seem pretty good, so I should be thankful for that.

Meanwhile my leg is waking up. Last week I had this uncontrollable urge to stretch every part of it. That sensation waxes and wanes each day and I feel I need to be careful not to overdue the stretching. Usually I feel much better after succumbing to the urge. But still scares me a bit at how much my body so wants to be back to its previous normal two-leg walker self.

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May 12 2014

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goldman

Operative Report

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It’s now seven weeks, six days since my ATR operative procedure. I’ve been meaning to upload this for a while, finally got around to a) finding it, b) scanning it in, c) sanitizing the data. The scans following this post are the operative notes that my surgeon wrote shortly after the early morning procedure on March 18, 2014. I’ve removed IDs and names other than mine. I thought that this might be useful for other people to see the technical notes from an ATR repair that I think was mostly run-of-the-mill. Also, while I have read through it, I don’t know all the technical jargon yet, so I haven’t quite deciphered the entire procedure into layman’s terms. For example I have yet to determine if the #2 polyethylene FiberWire sutures are disolvable, or if they are going to be with me and my tendon forever.

The one deviation (I think) that my surgeon took from an even more run-of-the-mill ATR repair was to make use of the plantaris tendon (see page 2 of 3) to “improve” the healing of the Achilles tendon. I was told the day after surgery that it is a vestigial tendon, and that was why my doc used it to weave into the structure of the Achilles. On the web I found this blurb: “The plantaris is considered an unimportant muscle and mainly acts with the gastrocnemius”. I find this interesting because at the moment my right calf muscle, right around the gastrocnemius, seems to hang off my leg in a slightly odd way. I have no idea at this point if that is due to general atrophy of the region from lack of use and exercise and being in splint, cast, and NWB boot for a while, or if it has something to do with the plantaris. Perhaps others on achillesblog.com can enlighten me? One thing it might explain is why my heel is the most sore part of the area around my Achilles, and continues to bother me.

In the office the day before the procedure my surgeon described several possible things he might do to reinforce the repair once he got in and looked around. He mentioned animal tendon, such as pig; He talked about folding down some fascia, or something like that, but he didn’t mention the plantaris until two days later. I guess one should expect a pro to improvise as they see fit. Yet it feels a bit different when my Doctor does something unexpected inside my leg while I am asleep, compared to for example when my mechanic fixes an electrical short by cutting a cable under the hood and replacing it with something he likes.

Driving in my truck, and a man comes on the radio

Driving in my truck, and a man comes on the radio

Driving in my truck, and a man comes on the radio

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May 07 2014

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goldman

drive my imagination

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Driving in my truck, and a man comes on the radio

When I’m driving in my car
And the man comes on the radio
He’s tellin’ me more and more
About some useless information
Supposed to drive my imagination

7+ weeks post op — So I was sort of forced to drive my truck into work today. I had planned on just driving to the train station (4 mins away) for practice, and taking the train/taxi into the work office. But I forgot to get the handicap placard from my wife’s car, and there was no regular parking available, so I just said to myself: “Oh fraggit, may as well drive the 30 min drive all the way in”. Figured I would be beholden only to my schedule and not the Train/Uber combo I’ve been using for the past couple weeks. I had my winter shoe on my right foot. The shoe is quite large and roomy but my foot was so swollen that I could barely slip on the shoe. I had to wriggle _very_ carefully so as not to wrench my foot up too fast or with too much force. Between that and driving like a grandpa at about 25mph all the way on back roads it ’twas a bit anticlimactic. I was paranoid about injuring the tendon pressing on my pickup truck’s stiff gas pedal, and its old-only-manual brakes, so I kept my foot pointed in a funny downward slant and pretended like I was walking with the Aircast boot. I used the left emergency foot brake a lot to pre-slow down at controlled intersections. I’m sure I annoyed the hell out of every driver behind me today :-)

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May 05 2014

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goldman

CLEARED FOR DRIVING!

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HA HA HA, JUST got “official” clearance from surgeon’s office to start driving again. Look out teenagers, here I come!

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May 05 2014

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goldman

Welcome to the clot club part 2 - Xarelto no bust, and thankfuly no slip-ups!

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This is a continuation of sorts from my April 16 posting when at that time I was diagnosed with DVT. Last week I met with a vascular specialist at my hospital for an approximately two-week followup from the “incident” and to discuss the prescription of Xarelto and blood thinners in general.

Let me begin by saying that I had one of the most enjoyable visits to the hospital, any hospital ever. I was arriving yet again with my wife and 10-year old son in tow and some trepidation from the memory of my last Xarelto-based visit. Whereas the last visit involved several hours captive in the ER and my blood pressure sky high, this visit ended after 45 minutes with me feeling completely informed, my blood pressure at a cool 120/80, and reassurance that recovery was on track and we had made the best decision possible. My visit entailed meeting with Ann Pianca, a nurse practioner who was so knowledgeable about blood clots and the various prescription drug therapies, and so good at explaining them, that I was somewhat blown away. Made me think, “Man — if the doctors and surgeons at this hospital (Lahey Hospital in Burlington MA by the way) would only emulate Ann, Lahey would be number 1, rather than number 4, in the Boston area.”

My posts sometimes tend to the long side. For this reason I will cut to the chase for other blood thinner consumers or potential users reading this post that depending on your personal health history and body chemistry, if you are thinking about taking or are prescribed Rivaroxaban because you are a “good fit” for this medication– I can assure you that you have or will have made an excellent choice. So there you have it. If you want to exit this blog before getting drawn down the drain of my ramblings, do so now; I bear you no ill will, and wish you the speediest and nicest recoveries possible. I tip my hat and bid you adieu.

For those achillesblog gluttons of punishment that want to hear more, read on!

From the moment Ms. Pianca entered the examining room, to the moment we left I felt like I/we were being handled and informed by a real professional. She started out the conversation by advising us exactly how long we would be with her and what to expect from this visit. I interjected that my goals with the visit were three-fold: 1) To find out how long I would need to be on blood thinning medication, 2) Learn more about Xeralto, and 3) If I didn’t like what I heard to determine the fastest and most efficient means possible to switch medication.

Ann assured me that all my goals would be met, and more. She proceeded to outline the basics of the human circulatory system, explaining blood flow as we learned in high school and college anatomy classes. She explained why clots happen and how they are treated, the anti clotting mechanisms of Xeralto and Cumadin, since those are the two main thinning medications that are prescribed. There are several other medications, but some have more risky side effects, and/or are less well known. In any event for a person of my age (52) and health history (healthy except for the ATR and some previous high blood pressure and high cholesterol) those are the two choices. For people with more complicated situations, for example cancer, diabetes, older, etc. the other medications come into play.

One of my main concerns with Rivaroxaban is the known non-reversal component. This means that the anti-clotting features have no known way to be stopped. Where cumadin can be counteracted with vitamin K, Xeralto continues to work its “charm”. The implication is that if one is to suffer a traumatic injury while on Xeralto — one is going to bleed. The big concern is with internal injuries. This was the main reason I was planning on getting off Xeralto once I returned to driving. So I had been watching the calendar, relieving my wife of (some) of the many doctors and hospital visits that she has had to drive me to, and I figured that while I am non-driving less likely I will suffer a bleeding type injury. I had been thinking up to this point that I was going to switch to Cumadin, until I talked it out with Ann. It’s a bit complicated, and I will try to relay accurately what she told me, but the reader is advised with the usual caveats: do your own research, be your own best patient advocate, and make the decision that you feel most comfortable with. I can only relay my experience and contentment with sticking on Xeralto, but your situation may differ.

Anyway, back to the story about bleeding. Well it turns out that all the blood thinning medications (as far as I know this applies to all of them) have a half-life. Which means that the anti-clotting mechanism lasts only so long, at which point it needs to be re-inforced. By you guessed it - taking more medication :-) Rivaroxaban has a half life of 5 to 13 hours in most people. The implication being that if you do suffer a serious injury - you only have to wait a few hours before the anti-clotting mechanism stops and you can be treated appropriately (e.g. surgery). Cumadin on the other hand, has a much longer half-life - something like 20 to 60 hours. Now cumadin can be counteracted with vitamin K, and this is where I lost Ann a bit. But the vitamin K can’t be administered right away, or its effects don’t take right away, I am a bit hazy on this point. Patients can be treated with plasma infusions, but there are some limitations there as well. The big concern with Xeralto is dealing with head and brain trauma. What I gathered from Ann is that is one risk that can not be circumvented by other means (I’m sure there are other bleeding risks too, but she focused on that one), but as she put it: “Be careful. Wear seatbelts. If you ski, wear a helmut and know that if you hit a tree, well hitting a tree is risky whether on blood thinners or not.”

One of the main benefits to Xeralto over Cumadin is that it’s chemical properties make it a much smoother release into a person’s system. It’s just a pill, once or twice per day, and requires no monitoring. Cumadin requires monitoring which means more visits to the clinic, to assess it’s effective level and the dosing can vary greatly between patients. So after all the discussion of the half lives issue, and ease of use of Xeralto I was whole heartedly convinced to stay the course. I will be on the medication for about three months, at which point I will return for an ultrasound and appointment. One thing that I was surprised to learn - regardless of the ultrasound in three months, I will be taken off the Xeralto. I’m not really sure what happens from there, because Ann told me that once a blood clot forms, it’s much more likely to get them again in the future. So I guess I’d be back on one of the medications if that were to happen.

We ended the visit with a discussion of compression socks - with her telling me that I would need to wear those for two years, once I get out of the boot. Unfortunately the socks are a bit pricey, and not all insurance covers them, and some people can’t stand to wear them regardless.

So that’s my latest clot club update, until around July 11. Happy Healing!

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