Part four…Tendon Augmentation and Time For a Second Opinion, or Two.

Having spent five hours at the sports orthopedic hospital on Tuesday, I was not thrilled about coming back to see their foot and ankle specialist on Thursday. I knew it would mean starting from scratch, filling out more paperwork and more waiting, before we got the important conversation about surgery options. Sure enough, not only did I have to fill out paper, but somehow my file was not transferred from the referring orthopedist who I had seen in the same medical office not 48 hours before. Once I got everything straight, I was put in an exam room where I sat for close to an hour while I heard the foot specialist talking in the corridor. When he finally entered and we dispensed of my recounting details of the occurrence of the injury for what was now the fourth time, the foot doc interrupted to say that my rupture was very bad, bad enough that he felt there was no way to repair my Achilles with simple suturing and that he wanted to do an augmentation procedure. He felt that the best way to proceed was to remove my flexor hallucis longus (FHL) tendon, which runs from the heel to the “knuckle” joint of the big toe, where it bends, and weave this into the Achilles breach for support.

When I asked him what the negative ramifications may be, he said that I would lose some flexion and power in the push-off in the front of the foot. As an athlete, that didn’t sound like an attractive option; even if I am unable to play basketball again, I would still like to have power to push off to play tennis, or just run. I wondered whether I would even be able to negotiate stairs easily without that tendon. I asked if there were other options, and the doc said no, that was about it. He then left to go check on his surgery calendar for the next week so he could schedule me for the following week, and disappeared for close to another hour. Frustrated, I asked an assistant in the hallway to call the original orthopedist, who I had seen the other day. After about 15 minutes he re-appeared, with the foot man in tow. They reiterated the FHL x-fer choice and procedure, but when I looked into the eyes of the first doc, I couldn’t get what I could read as a 100% go sign. I like him and felt very comfortable with him; if we had gone through with the originally-scheduled routine AT repair on Friday it wold have been a done deal. But I didn’t feel confident in the foot man, and I didn’t like the way this new procedure was being thrust on me by him without any options. I asked that they do the surgery together as a team and they agreed, the first doc would do the achilles work and the foot guy would transfer over the FHL. I walked out behind them into the hallway where they could check the surgery schedule, and the original doc said he was available on the following Monday or Wednesday, but the foot man said he could not do it until the following Friday. That raised another red flag for me; I had read that ATR repair should optimally be done within 14 days of rupture, and this would take my surgery out to 11 days. I was facing a dire dilemma: I was ready to go and didn’t want to wait 8 more days, but this was Kerlan-Jobe, one of the world’s most pre-eminent sports orthopedic hospitals. And I wasn’t convinced abut the technique, or the doctor recommending it.

I decided to hit the internet that night. I also emailed and phoned a few other orthopedists. First I tried to learn as much as possible about FHL x-fer, but I could not glean much information. One of the articles I read said that I could lose between 20% and 30% of the power and flexion in the front of my left foot, which is my push-off foot in sports. I also began sending out leads to find another sports orthopedist in my area so that I could get a second opinion. The search was appearing futile, and as of Friday afternoon, I had not turned up a good choice. Then serendipity prevailed. I am somewhat of a “wine geek,” and one of the guys in my wine-tasting group works on a wine and spirits store. Feeling sorry for myself, I decided to drop in and buy a bottle of tequila. Though I rarely drink tequila at home, I thought this would be the weekend to do it, and after my fried recommended and excellent anejo we began talking about my injury. Out of nowhere, he asked if I remembered a guy who had been a gust at one of our group’s wine dinner this summer. He had great taste in wine, was buying bottles from my friend and, coincidentally, a sports orthopedist in the South Bay who works on some of the L.A. Kings and has achilles experience.

Five minutes later I was on the phone with the new doc, who told me to come down to his office, and 90 minutes later I met him face to face, carrying my MRI on a CD and my radiologist’s report.

(To be continued in Part Five…)

Part three…The Good News and the Very Bad News.

Knowing immediately from having seen other b-ballers do it and from prior internet research that I had an ATR, once in the car (no problem driving since the injury was to my left foot) I called the Kerlan-Jobe Orthopedic Hospital. K-J is one of the best in the world, work on all the L.A. pro and college sports teams, and had treated my ankle tears and done my wife’s knee. Our regular doc wasn’t listed as an Achilles specialist, so I was referred to another one their docs, who lives in my neighborhood, but I had never met. When they heard I was a rupture, they squeezed me in for the following day, Tuesday at 2 PM.
The doc was great. He knew right away, but gave me a quick Thompson’s test to confirm. Meanwhile, I  had gotten use to the condition, was not feeling pain, and was able to put pressure on my foot and even walk. I asked about simple casting, but upon quickly realizing that I was in good shape and intended to go back to sports (hopefully even basketball even though I will be nearly 54 when this treatment process is over), the doctor talked out of that and into surgery. I found it odd and discomforting that in the past I had experienced left ankle injuries marked by exquisite pain, which was usually abated by medical treatment, but here I was with an injury that didn’t seem so bad yet I knew was going to get worse before it got better and that the pain would come from the fix — the surgery. Nevertheless, of course I opted for the surgery, asked to have it ASAP, and was slotted in for Friday morning.

I was fitted for a CAM boot, and the doc ordered and MRI for me, which is conveniently in the building, but was inconveniently booked solid until 6:30, so I hobbled across the street for coffee for a couple hours. After the MRI, the radiology tech invited me to have a look, and it appeared to me that although their was a clear rupture, that there may still have been some strands holding the Achilles together. The tech said he couldn’t tell, and that the radiologist wouldn’t read it and offer a diagnosis until the following morning. Still, I went home thinking this is good news, it would be a simple surgery and hopefully a speedy recovery. 

On Wednesday, I called K-J, and my doc wasn’t able to return until late in the afternoon. When he did, it was to tell me that yes, while there were some strands still held together, and the ruptured ends did not roll apart like “window shades,” the damage was actually much more extensive than he had anticipated. He told me that the chronic tendinitis had been wearing down the Achilles fibers for years and that what I had was a plate of “spaghetti,” which would be difficult to suture together. He cancelled my Friday surgery, and told me to consult with the clinic’s foot specialist, who was recommending a tendon transfer, and would perform the surgery with him the following week. I made an appointment so see the foot man the next day.

(To be continued in Part Four…)

Part one…Case History. The Cliche of the Weekend Warrior.

I actually injured my achilles 10 days ago, and just had surgery two days ago. While lying in bed, I was doing some research and came across Dennis’s blog, which looked helpful and interesting as I too ruptured my AT playing basketball, and I thought I might add some of my own thoughts on this blog, as there have been some differences already in our cases. 

To begin at the beginning… 

I am a 52 year-old male who has been playing competitive basketball for over 40 years. I have had other exotic basketball-related injuries in the past, such as avulsion fractures where the ligaments were actually torn off the bone in the ankle. Twice. Nevertheless, I continue to play, two or three times a week, full-court, for about two hours each time, mostly with players much younger than I. Although I am not nearly the player I once was, I remain in very good shape and am still close to the top tier. I run hard from the start of the games to the finish.

About five years ago, I started to develop pain in the backs of both of my ankles. It became difficult for me to play through the pain, and I inquired into it with a distant family relative who is an orthopedist. She pronounced it achilles tendonitis, and when I asked her if there was anything to do about it, shrugged me off by saying: “stretch more.” Admittedly, at that time, I was not doing much stretching. I checked in with the brother of a friend who was doing his residency in sports medicine at UCLA and he seconded the opinion that it was indeed achilles tendonitis, and when I asked him about treatment, confirmed that stretching would be the best thing. I also checked in with a chiropractor and an acupuncturist, who offered differing opinions on the physiological mechanics of what was happening but seemed to agree that the hamstrings in both legs were extremely tight, and that I also my have had calcifications. The chiro also recommended orthotics and fitted me for them, and gave me a series of stretches to do on my own. I also enrolled in my first yoga class, taking “slow stretch yoga” with about seven geriatric ladies, which seemed perfect for my tight leg hammies. The yogi too gave me some stretches to do on my own.
After a bit, the tendinitis seemed to abate. If the backs of my ankles got sore, I would simply stop playing. I also regularly wore the orthotics in my bball shoes. 

(To be continued in Part Two…)

Part two…Let ‘er Rip. The Textbook Example.

Anyway, I had been playing with no issues for the last several years until…suddenly about a month ago I woke up the day after a game (I always play either Monday and Wednesday or Tuesday and Thursday so that my body gets at least one day of rest in between), and the backs of my ankles were on fire. From out of nowhere I thought. I was doing the same extensive stretching program as before. A couple days later I played again, and while I was sore, it wasn’t painful enough to quit. I did, however, decide to shut down, and went back to the chiropractor. Same analysis: tight hammies and probable tendinitis. Over the course of two weeks, I went for twice-weekly massage, electro-stimulation and ultrasound. While talking to her, I realized I had perhaps made a critical error. I got new basketball shows a few months ago, and the type that I wore religiously are no longer made. After some research, I found a pair that was similar and bought them. They were, however, tighter than the old ones, and since I had been feeling good in the ankles for a couple years, I absent-mindedly forgot to switch in the orthotics.

For good measure, I enrolled in a new yoga class, Iyengar 1, a system designed to hold poses, which is very good for stretching. Two weeks ago I attended two classes, then feeling pretty good with all the work, returned to playing basketball on Thursday, January 22. I popped the orthotics into the new shoes, then played but took it easy, and felt pretty good. When the backs of the ankles acted up, I called it a day. The next day I was sore and visited the chiropractor for treatment and over the weekend the pain abated. I decided to play on Monday and Wednesday the following week, and practice yoga and Tuesday and Thursday.

On Monday, January 26, I popped two Advil to preclude inflammation and got to the gym a little early to warm up and stretch. The gym was very cold. I started playing and felt relatively pain-free, so I decided I could be a little more aggressive. About 90 minutes into the game, I had the ball and started to make a power move to the basket. I felt a strange pop in the back of my left ankle, and the proto-typical symptom: I thought someone had thrown another ball, hard, at the back of my left foot as a joke. I turned around to yell, saw that there was no one within 30 feet of me, and realized immediately what had happened. I managed to limp to the bench and  said “I blew out my achilles.” Oddly, it was not very painful, nowhere near the pain I had experienced with my worst ankle ligament sprains and tears. In fact, the rupture completely eliminated the pain in the back of my left ankle. Ironically however, the back of my right ankle continued to burn (and is still inflamed to this day, even as I write this).

Two guys in the game carried me to the car; one was older and the other younger — they had both had ATR’s. 
“How long,” I asked.

“One year,” they both said.

More tomorrow.