two shoes — again!

I saw my OS last Monday, a week after the PT put me back in the boot.  As much as I hated wearing the boot again, I had to admit that it was the right move, and actually wore it for a day or so after the doctor’s visit.  The OS wasn’t terribly concerned; he said that the soreness was located where the tendon flares and attaches on either side of the heel, and that while this isn’t common, it’s nothing to really worry about.  He prescribed an ointment with gabapentin (neurontin) and lidocaine and told me to apply it 3-4 times/day as needed.  I asked if I should hold off on PT for a while, and he said no, but to start all over again.  So Friday, it was back to seated ROM exercises — circles, alphabets, etc. — and resistance exercises using the red theraband (I had been up to the grey).

So far so good.  I do have to be careful on the (recumbent) bike to make sure I have my heel on the pedal, and can’t wear my favorite shoes (Merrell clogs) for the foreseeable future, but my ankle is feeling better today than it has in a couple of weeks.  I’m walking almost normally again, too — in other words, about as well as I was before the flare up.  Not what most people might call normal, but about as well as can be expected at 16 weeks post-op.

I’m still not sure what caused the problem, but I suspect I wasn’t paying as careful attention to things as I should have been and had slipped into several habits that aggravated my ankle.  Among other things, I’m now trying to unlearn a decades-old habit of counting time to music with my right foot, and trying to use my left foot instead — old dogs, new tricks?  We’ll see.

Back in the boot…

It’s been a tough week; last Monday at PT I found myself unable to do exercises I’ve been doing pain-free for weeks — heel raises (two legs, of course) and step overs — basically anything that required me to push off with my right foot.  We scaled back for the day and the PT told me to take it easy during the week, so I taught sitting down and did mostly upper-body work at the gym (the good news is that my shoulder doc released me, so I’m restriction free there!).  At Friday’s session, the pain was still there, so I had ultrasound, iontophoresis (e-stim with a topical med), massage, and ice (not in that order).  I went home with instructions to wear the boot if I was going to be active (I wasn’t:  too much grading to catch up on).  Today things were no better.  In fact, my ankle is starting to feel like it did pre-surgery; pain at the site where the Haglund’s deformity was, and pain in the tendon after fairly limited activity.  Today’s instructions were to wear the boot even around the house until I see the surgeon, which will be next Monday.  PT is on hold until the doc sees me, too.

I’m hoping that this is just a hiccup, but am worried that the bone spur is reforming and irritating the tendon. I tried to find data on reccurrence of Haglund’s deformities, but could only find advice for avoiding recurrences (no running on hard surfaces or up hills, no rigid-heeled shoes.  I’m innocent of those, and have been doing the two things they recommend, including wearing arch supports and achilles stretches.  ROM has been normal since week 8.)  I do apparently have the kind of foot that lends itself to this kind of problem, though:  high arch and lots of mobility in both forefoot and rearfoot.

At least I’m getting my money’s worth out of my vacocast :)

Remembering my limits — and bed wedges

Last week was my first, official 2-shoes week; it coincided with a very full schedule that included a charity dog walk on Saturday.  Even though the walk was only a mile long, my PT told me to wear the boot — better that than tripping over or getting tripped up by one of the dozens and dozens of dogs around.  To be honest, I was happy to put it on that morning; by Friday evening, my foot had begun to ache.  It was clearly a result of fatigue/overuse, but it was sore enough that I spent as much time as I could over the weekend lying down with my foot elevated, icing it regularly. I still had some residual soreness at Monday’s PT appointment — standing seems hardest on me — but Tuesday morning was pleasantly surprised to wake up pain-free *and* walking more smoothly than ever.

Monday afternoon I saw the orthopod who repaired my shoulder; he said he worried about people who had little or no postop pain, as they were the ones who were more likely to do too much too soon and reinjure themselves.  I decided that was my cue to a) wear my boot when I fly in a few days and b) to consider using the airline’s help in getting from gate to gate/terminal to terminal — especially since this is vacation, not work, travel :)

BTW, I discovered a great way for elevating my ankle in bed without having to worry about kicking pillows off or raising the foot of the bed.  Bed wedges, marketed to people with acid reflux and respiratory problems, are perfect.  They’re too heavy to kick off easily, provide support for much of my leg (no hyperextending my knee any more!) and don’t compress like regular pillows can.  I got one so I could sleep propped up after shoulder surgery, but have found it much more useful for my ankle.

Time flies: two shoes and “real” driving

I had a slight surprise at PT this morning when I realized that I was almost 9 weeks post-op and not 7.5.  I decided that was a better mistake than thinking I was further along than I really am.

I wore two shoes at last Monday’s PT session, but was told then to use the boot for all but short distances.  As it turns out, I’ve only had it on twice since then — to work on Tuesday, and then to go out to breakfast and run errands on Saturday.  Part of that decision was based on wanting as much normalcy as possible, but part of it was driven by the fact that I had shoulder surgery on Wednesday and didn’t really want to rely on other people to help me get dressed. Fortunately, it’s still warm enough here to wear sandals, which I could just slip on.  They have a very good arch support, so my foot/ankle wasn’t stressed too much.  By this morning, I had enough ROM in my shoulder to be able to tie my own shoes, so put on a pair of 1/2-size-too-big Merell hiking shoes (with a pretty flexible heel counter to minimize pressure) and headed off to PT.

It was a long session (I’m rehabbing both injuries at the same time, but paying only one copay!) and tiring. Today was the first day I’ve stretched my achilles while standing;  we added in multiple sets of step-ups, step-overs, balance exercises, and several different gait exercises.  As lots of others here have said, there’s a big difference between how I walk when I move slowly and concentrate, and how I do when I’m in a hurry and/or not paying attention.  I probably would have avoided several injuries over the years if I’d moved more slowly and paid more attention to what I was doing; too bad it took achilles surgery to get me to realize that!  At the end of PT, I asked again about using the boot; this week, I was told to keep it in my car for those times when I would be on my feet all day and might need a break.  Tomorrow will be the first day that most of my students will have seen me without a boot on!  There is still almost 1.5 inch difference between the two calves, so I still look lopsided.  I’ll just have to dazzle people with the smoothness of my gait :)

The left-foot accelerator has to be back in Indiana by the middle of this week, so I shipped it off on Saturday and started driving with my left foot for the first time in over 8 weeks.  I moved the car seat a little closer than I usually like it so that it would be easier on my ankle, and put about 50 miles on the car on Sunday. Other than a little fatigue near the end, it felt pretty normal.  I’m very happy with the decision to rent the accelerator; it let me get as much of my life back as possible under the circumstances.

7 week post-op appointment

I’m just past 7 weeks and saw my OS today.  The PT did a progress report this morning before I saw the doctor, and I’m 7 deg. dorsiflexion, 60 deg. plantar flexion (it was measured twice because that’s high even for healthy ankles), something equally high (47?) on inversion (lots of ankle sprains in the past), and normal eversion.

The therapist did add new exercises today — the balance board (in the boot), walking heel-to-toe around the room several times, and balancing on my right leg while my left one tapped the tops of cones placed in front of me.  I’m still blown away by how difficult seemingly normal activities are these days; I look like I’m drunk when I’m trying to walk a straight line, even in the boot!

I’ve developed a fair amount pain on the inside of the ankle (where the FHL tendon is now attached?) but the doctor didn’t seem concerned about that; he didn’t seem concerned about anything.  In fact, he said that unless I were having problems, I wouldn’t need to see him again.  He is leaving it up to my PT to determine when and how to transition to 2 shoes (i’m taking my right one to therapy on Monday!) and when I can start to resume other activities.

This is great news, especially because I’m having shoulder surgery in 5 days, and was counting on being on track with my ankle before then.

I’m doing a charity dog walk in early October.  It’s only a mile, and it may be too optimisitic to think of doing it in 2 shoes at 9.5 weeks, but I’m trying to tell myself I’m training for a road race or a long hike.  It’s something to look forward to, anyway and a way to avoid thinking of just how many more weeks and months I have to go until I’m back at full strength.

two shoes question

I’ve been reading a lot of these blogs recently, but am not sure I’ve ever seen anyone say what criteria their doc/PT use to determine when they can move to two shoes.  I know there is a wide range of rehab protocols among site users, but I’m wondering what rationale(s) drives the decision.

thanks!

Carol

Driving, PT, and FWB?

It’s been a big week already.  On Monday I used the left-foot accelerator and ran a bunch of errands around town.  It was a good day to try real world driving out without normal weekday traffic.  I stayed off the interstates, figuring that they’d be crowded with end-of-holiday traffic, and stuck to surface streets.  Between the errands (on crutches, instead of the scooter) and the gym, I was exhausted by the time I got home but pleased that I was getting back some of my independence.

Yesterday I lowered the angle on the vacocast to 5 deg. plantar flexion, and this morning walked to the car, carrying my crutches!  It wasn’t pretty, but it also wasn’t too uncomfortable.  I had my first PT appointment, and was pleased to see that with AROM, I got to neutral and that with PROM, was easily past neutral, without pain.  In fact, the PT said I had better dorsiflexion in my injured leg than he did (not sure what that says about his flexibility, but I took it as a good sign.)

There was a PT-assistant-student doing a clinical rotation at the clinic; it was pretty disconcerting to have the therapist use my calf to demonstrate to her how significant atrophy looks and feels — especially when the student compared the muscle tone in my calf to that of a stroke patient!

I also made sure to show off the vacocast to the staff; they’d never seen one but were suitably impressed by it, especially the assistant who’s about 3 months out from an ATR surgery himself.  The PT wants info on the boot so that he can introduce it to the physicians he works with most frequently (not the practice where my OS works).  The PT is also going to contact my OS’s office to find out if I have to stay in the boot until I see the doc again (on 9/20), or if the PT can make the call on moving to two shoes; hopefully he’ll get the okay on that one.

I was PWB last night, at PT and on my way into the gym this morning. By the time I left the gym though, I was FWB and continued that way until I got home — at which point the first thing I did was put ice on my ankle.  I’ll keep the crutches handy, but am thrilled to know how close I am to ditching them for good!

I’m still really pleased with how well my achilles seems to be healing — not being able to curl my toes yet is frustrating, but in the overall scheme of things that’s minor — but what is surprising is how tired I am all the time.  I’m sure some of it is the product of deconditioning in the months prior to the surgery, when almost everything hurt my achilles so badly that I quit doing a lot of activities, but I also have to face the fact that some of it is likely due to age.  My 50-something body just doesn’t heal as quickly or easily as the 20-something version did.  Not much I can do about that, I’m afraid!

Four-week post op visit

I had my four-week post-op/second post-op visit today and am very pleased with how it went.  At my last appointment my OS had told me to wear the boot only for practicing walking, so at home I rarely wear it.  At work, though, I have it on even when I’m using the scooter, mainly for protection/security.  Thirty minutes into my 3 hours of teaching, my incision would begin hurting, despite the fact that I was always in a chair with the leg propped up.  I had planned to wait until this visit to discuss the vacocast with my doc, who wasn’t familiar with it, but decided not to wait, and ordered it Monday.

The boot arrived on Wednesday and Thursday’s teaching was so much more pleasant; I had the boot on for about six hours without pain.  When I wore it to today’s appointment, the first thing the nurse said was, “Wow!  Cool boot.”  I started explaining all the features and handed her the vacocast.com pages I’d printed for the doctor.  As she was leaving the exam room, she saw him the in hall on his way to see another patient, and insisted he come check out the boot.  He seemed impressed, though really didn’t have time just then to really check it out.  I hope he looks up all the information I gave him, as the nurse said the vacocast cost about the same as the boots they currently use.

I had forgotten at my last appointment to ask him about the condition of my achilles.  I had assumed that less than 50% was in decent shape since he went ahead and did the tendon transfer, but today he said it was in really bad condition — which makes me regret spending as much time as I did listening to the first OS.  Oh well, lesson learned.

He looked at the incision (it looks good), watched me do a couple of seated calf raises (I can get my heel about 4cm off the ground), gave me a choice of whether to do rehab on my own or with a PT (I chose the PT), and told me I can start FWB as tolerated!  That’s exactly what I was hoping for.  On the other hand, I don’t see him again for 3-4 weeks, so unless the PT makes the call on two shoes, I’m in the boot until Sept. 20.  At least it’s the vacocast.

I celebrated by having the friend who was driving me drop me at the gym so I could work out on machines and with heavier weights than I have at home.  I was cleared at my last post-op appt to ride a stationary bike as long as the resistance was set to zero.  I figured today  that if I’m allowed to start working on FWB, then I can also increase the resistance on the bike; I set it at my pre-surgery level but lasted for only five minutes before my achilles started getting uncomfortable, at which point I cut the resistance in half.  Still, it felt so much better than pedalling with no resistance at all.  Because I’m not FWB, I used machines for lower body work, using both legs for leg raises, but only my good leg for the hamstring curls; the bar hits right about where  the incision is, and I decided to play it safe.  I’m tired now, but in a good way.

I’m now investigating PT clinics in the area.  I’ve been to two here in town, including while I was trying to rehab to avoid surgery and they’re fine, but am hoping to find one with hydrotherapy and a PT who is willing to use it; I’d do that part on my own, but the pool at my gym in an outdoor pool and will close for the season soon.

I’ve got the vacocast at 5 degrees plantar flexion but cannot do FWB at that angle; I was guessing at the 5-degree angle to begin with, since I didn’t know how to translate one wedge+plus leather top into an angle; it feels fairly close to where I was in the old boot, though.  Should I try increasing the angle to 10 deg. and trying FWB, or stick with the 5 deg. and use the crutches more until it’s more comfortable?  It seems like I’ve read that some people are FWB at 15 deg. or more, but don’t know whether that’s an approach that’s widely recommended.  Any and all advice will be welcome!

Carol

left-foot accelerator?

Has anybody had any experience with a portable left-foot accelerator?  If so, would you recommend renting one? I have wonderful friends and colleagues who will be driving me to and from work, but I suspect the loss of independence will become increasingly frustrating before too long.  I could try using my left foot on the regular accelerator and brake but it’s pretty awkward — it almost makes me wish for the days that cars had bench seats in the front so that it was possible to slide over some.

late joiner: surgery 7/31; now PWB

I wish I’d known about this site before I had my surgery; I almost certainly would have saved myself several months, if not years, of pain and hassle.

I’m 19 days (7/31/13) post-op — debridement, Haglund’s excision, and FHL transfer. I originally injured my achilles in 1994, carrying a backpack and laptop up a long, steep hill. I was in grad school at the time, and had limited health insurance so didn’t seek treatment. It’s flared up periodically since that time, and I underwent weeks and weeks of PT over the years. It finally got to the point where I was unable to wear any kind of shoe with a back to it and had quit doing a lot of the activities that I enjoy.

The first OS I saw this most recent flare was a sports medicine guy who is really a shoulder expert so when I “exhausted his bag of tricks” he sent me to one of the foot and ankle specialists in the same practice. Aside from ordering an MRI, seeing the second doc was a waste of time — had I known what I know now, I would have sought a second opinion much sooner — the 2nd OS did not want to do surgery, even as a last resort. Instead, he suggested PRP injections (platelet-rich plasma), though admitted that he had little experience doing the procedure himself. I read every study I could get access to and decided that, while the procedure may have potential, there were still far too many questions and far too little convincing data to go ahead with it, especially as my insurance wouldn’t cover it. Besides, it wouldn’t have treated the Haglund’s deformity.

I got the name of two more foot/ankle OSs in the area and tossed a coin as to which one I’d try first. The 3rd OS, also a foot/ankle guy, looked at my MRI, and immediately started talking about what kind of surgery I needed. While I wasn’t thrilled about having to have surgery, I knew he was right. He also confirmed what I’d already learned about PRP and I felt very comfortable with him, so scheduled the surgery at that first appointment.

And not quite three weeks out, I’m so happy I did. Within a couple of days, I was having less pain than I did pre-surgery. I’ve gone through major joint rehab before, so I know that there will be soreness, etc. to come, but based on pain (none) and ROM (not bad!) so far, I couldn’t be happier.

I was lucky in the anaesthesiologist who was assigned to my surgery; apparently not all the anaesth. around here are willing to do this w/o general anaesthesia, which I did not want to have. “My guy” did a saphenous nerve block and a popliteal block; they filled me full of versed and topped it off with a little propofol and that was that. I woke up, completely alert, while the surgeon was dictating his notes in the OR after the procedure.

Pain medicines and protocols have improved dramatically in the 30 years since my last orthopedic surgery. I was off the meds two days later and except for preventative pain relief following a slight fall, haven’t had any since that time.

I had the spint and sutures removed on 8/12 and went into a boot with about a inch heel lift — smaller than I had anticipated. I had more plantar flexion in that ankle than I expected, too, though my ROM pre-surgery was normal. The OS had told me in the spring that I’d remove one layer of lift every week, but on Monday he said to do it every 3-5 days. He also said — and this was the best part! — that he wanted me to wear the boot ONLY when I was “practicing my walking.” I was surprised, and just to make sure, asked if that meant I didn’t have to sleep in it. Absolutely not. Having slept in the boot for several weeks over the last couple of years, I was thrilled to be told *not* to do it. I’m hoping that when I see him next, on 8/30, I’ll go to FWB in the boot.

I’ve also been given permission to start working out again; before the surgery, he had told me I could not ride a recumbent stationary bike, even with my injured leg propped up on a chair. At Monday’s appointment, though, he not only gave permission to ride that way, but said I could even use my right foot, as long as the resistance was set to zero. I worked out with my trainer at home on Wednesday, and at the gym on Friday. Being able to exercise again has definitely made a difference in my outlook!

I’ve been PWB for 6 days now, and am pleased with how it’s been going. I had thought that I wouldn’t be PWB until 4 weeks post-op; now I’m revising my timetable for being able to drive (it’s my right foot) down, too.

I’m also lucky in that, as a college professor, I’m on a 9-month contract and didn’t have to take sick leave for this. Meetings and classes start this week, though, so I’ll be putting more demands on my ankle than I have yet this month. I do have a knee scooter that I plan to use at work and a extra set of crutches a friend lent me so that I don’t have to carry them back and forth to school.

The one disheartening component of this is how quickly my right calf has atrophied. I knew it would happen, and happen quickly, but I was still shocked at the extent of loss. I don’t known when I’ll be allowed to start PT; I’m hoping the doc will write the script for it at my next appointment, so that I can start rebuilding that leg.

I’m sure I’ll have periods when I’m frustrated with the progress I’m making — or failing to make — but I’m much more optimistic about returning to normal activities now than I have been in quite a while. I just need to try to remember my state of mind now when I hit those plateaus.