Lucky Number Seven: Seven Years

This blog started years ago as thoughts from a runner with two debilitating Lisfranc injuries. It's now been seven years since my last hardware removal surgery. The transition back to a full active life hasn't been without it's road bumps, but overall the experience has been positive. The main challenges I have met are getting my biomechanics and musculature back to working order. After four years 2014-2018 of being mainly off my feet, there was significant atrophy of muscles and ligaments which required slow and constant work to strengthen these features once again. There have been strange pains and soreness along the way, but ultimately I have been able to get my body back to a solid physiological state. 

Hiking in Glacier NP

The good news is that I have now been able to get back to my pre-injury self and don't think about my feet at all. More importantly, I have been able to get back to the things I love doing and that make me feel happy. There hasn't been a opportunity to hike, bike, frolic, or run that I have passed up. This summer I visited Glacier NP and while I admired the beauty unfurled in every direction I also stopped to acknowledge the deep gratitude I felt for being physically capable of exploring such a wonderful place on my two feet.

For you runners out there that are interested in the ability to get back into running after this sort of injury, I will say that it is possible given the right treatment and hard work. I have now been back into long distance running for the past four to five years, progressing to longer and faster runs. The past two summers I have competed in trail running series, racing 7-9 miles in the mountains each week during May-August, and this summer I also ran an ultra distance trail race (50k). For reference, I have been averaging 20-30 miles a week running as well as doing cross training road and mountain biking. I couldn't have even imagined running one mile let alone tens of miles seven years ago after my last surgery. There were doctors that told me that I would never walk without pain again in my lifetime and to completely forget about ever running again. I never accepted these prognoses and fought hard to find the solutions and help that I knew would bring me a pain free and active life again. 

Hiking in Glacier NP

If there is one thing I could say to anyone going through a Lisfranc injury, it is to be your own advocate and don't accept a doom and gloom fate. I understand that battling with a Lisfranc injury can become tiring and eventually it can become easier to stop fighting and concede, BUT DO NOT CONCEDE. Take any last scrap of energy and rally for what is best for you. I saw six different doctors over four years before I found the outcome that brought me to where I am now. Obviously, all our journeys are different and will have different outcomes, and maybe I got lucky. However, I don't fully believe it was just luck.

Doctors will give their varying opinions about treatment and prognosis, which is good but it can also make things confusing and overwhelming for the patient. There can be a sense of not knowing or feeling confident in what treatment is correct. For this reason, in one of my past posts years ago, I wrote this literature review about Lisfranc injury treatments and prognosis that describes the results from many different research papers and studies on Lisfranc treatments and their respective outcomes. I originally wrote the post to help consolidate the many sources of information that I had read to help guide my decision making process in finding help and treatment for my injuries. I highly recommend anyone going through a Lisfranc injury to read the post. 

A Lake it Glacier NP

I think one of the most important take aways from my experience is that I now live a life without a second thought about my feet and without pain or discomfort. For many years, I did not think this outcome was possible. The effects of a Lisfranc injury can root so much deeper than just physical ailments. It is an injury that can be insidious and consume a person from the inside out. The pain, physical dysmorphia, and the attendant mental strain can eat away at even the strongest person, leading to a myriad of accessory conditions including depression. For anyone who reads this, don't give up, don't concede, and don't accept any fate that is less than.   

Life and hardware free

I haven't posted in over a year. This is an update to my saga and my most recent right foot post-fusion/recovery and the subsequent hardware removal in both my left an right feet over last summer.

For those that are new or frankly can't remember (it's even hard for me at this point), here are a few bullet points outlining my Lisfranc/ankle problems in the first half of this year (2018):

• January 2018 - Right foot Lisfranc fusion after a prior Lisranc ORIF in Sept. 2016
• Jan-Feb 2018 - Non-weight bearing for 4 weeks to partial weight bearing in a boot for 4 weeks
• Feb-March 2018 - Weight-bearing in a boot for 4 weeks
• March 2018 onward - Walking without any boot or crutches. Hardware in both right and left feet from fusion surgeries in Jan 2018 and March 2017, respectively.

With a Lisfranc fusion in both my left and right feet by January 2018, I was finally feeling better than I had previously felt in the past 4 years. The recovery from my right foot fusion (Jan. 2018) was considerably better than Lisfranc surgery recoveries in the past.

I have been doing well the past 8-10 months. All my hardware has been removed from both feet and I feel great. As far as getting back to physical activities, I hike, bike, and even do a bit of running. But the biggest positive aspect has been my ability to get back living and just do normal things.

Fusion was the right choice for me, and from my experience/research I think it is the right option for many Lisfranc injuries. I have been through ORIF surgies in both feet prior to ultimately opting for fusions in both feet. ORIF failed for me, but doesn't necessarily mean it will fail for everyone. As I detailed in a previous post, the mechanism and type of Lisfranc injury will delineate the best type of treatment/surgery for the injury. Talk to your doctor, get multiple opinions, and do your own research. My journey was long and still continues. I hope that by sharing my story, and knowledge I gained along the way, I can help others going through their own Lisfranc saga. By no means should anyone take my experience and extrapolate it as what will happen to them. Every injury is different, and there is no one broad answer to a persons recovery. The most important take away I can give is to be your own advocate, stay positive, and get treatment as soon as you can. No matter what type of Lisfranc injury, the prognosis is always better if the diagnosis and treatment begin as soon as possible.

Soft bones and a fusion

Four months ago I was feeling good. Both of my feet were, for the most part, fine and I was getting back to a normal life. Then my body decided to give out on me again. It first started as a nagging soreness and dull pain that emanated from the inside of my right ankle. The soreness and pain emerged when I walked or stood but dissipated with rest. I initially thought the pain was from posterior tibial tendonitis. The symptoms correlated well - but a correlation does not mean causation. Over the course of a week, the pain only continued to worsen until eventually it lingered even with rest. The pain grew to a point where I could not even walk on my right ankle. I brought back out my boot and crutches. My ankle and lower leg were throbbing, and I knew the root cause of my pain had to be more than just tendonitis.

I saw my orthopedic doctor two weeks after the initial pain began. I gave him the details of my pain and he took some X-rays as the standard procedure. The X-rays came back negative, and the doctor told me I most likely had posterior tibial tendonitis. I knew my body, and considering the amount of pain I was in, I was not sold on the idea that all I had was tendonitis. I explained my doubts to the doctor and to make sure we discovered the correct injury he ordered an MRI. A few days later I got the MRI and received the radiology report the day after. In short, the report explained that I had tendonitis but also a stress fracture in my medial malleolus (a.k.a the inside ankle bone). I returned to the doctor a week later and he reviewed my MRI with me. In short, I had a stress fracture in my ankle and would have to be in a boot for 6-8 weeks. The tendonitis was in response to edema in my ankle.

The root cause of my stress fracture woes? Ironically, bone requires weight bearing to increase its density and strength. Bone in the human body is considered a tissue and is not static. Your body is continuously remodeling bone (i.e. removing old bone and building new bone). Without weight-bearing, this process slows down. My bones were soft in my lower leg/foot from many months (even technically years) of accumulated time that I spent non-weight bearing. 

Fast forward two months. I was back on my two feet and doing some physical therapy to strengthen my ankle and foot. Physical therapy helped and I was back to my pre-stress fracture activity (e.g. walking and biking). However, there was one problem I was still unable to shake. I noticed my right mid-foot was sore when walking. I knew the cause of the pain/soreness. I still had remaining hardware from my ORIF surgery in my right food a year prior (September 2016). With each step, the hardware irritated my mid-foot joint. The pain wasn't too bad and I could still walk around fine for the most part. But walking more than 1/4 mile was uncomfortable, and I knew that if I ever wanted to graduate to a higher activity level this problem needed addressing. 

I was warned when I first got the ORIF surgery that there was a likelihood that I could develop arthritis or the hardware could cause pain in the future. This thought was always in the back of my mind. For a year, I dealt with the discomfort with hopes that it would go away. I gave myself to the end of 2017 to make a decision. If the pain hadn't vanquished, I would consider the fusion of my first TMT joint and cuneiform. I knew from experience - with my left foot - that fusion could prove to be a viable solution to my problem. At the end of 2017, I spoke with my doctor. He also agreed with my reasoning and said that eventually, I would most likely need to get a fusion anyway. It would be prudent to go ahead and get it done now. So with a heavy heart, I decided to go ahead with fusion surgery of my Lisfranc joint. The only thing that made my decision palatable was the knowledge that the fusion of my Lisfranc joint in my left foot has given me great results.

The surgery took place at the beginning of this year (2018). This being my fifth surgery on my feet, I was unfortunately very accustomed to the pre-op and surgical procedures. My nerves were surprisingly low. In fact, the alarm on the heart rate machine kept on going off because my heart rate was below 42 bpm. I nearly fell asleep in the hospital bed waiting to be taken back to the operating room. The surgery went smoothly, but my surgeon did notice that my bones in my foot were noticeably soft. This finding wasn't unexpected, considering my history. 

The first three days after surgery are always the worst in terms of pain and discomfort and this time was no exception. However, the pain was tolerable and the swelling minimal. I have experienced worse after surgery. Two days out I even ditched my pain meds. The worst part of the post-surgery experience is coming down off of all the pain medications and anesthesia. It took five days for me to emerge from fog and nausea caused by my body's attempt to detox itself. Ten days after surgery I went to the doctor and got X-rays and the post-surgical splint on my foot removed. My doctor said the X-rays looked good and my incision had healed nicely. We spoke about my recovery options. Considering my history and my soft bones in my foot, my doctor advised that I start weight bearing sooner rather than later. Instead of going into a hard cast, I would be placed in a walking boot non-weight-bearing for three weeks then start partial weight-bearing. The tentative plan being that by 6-8 weeks I would be full weight-bearing in a boot. This recovery approach will hopefully help decrease bone density loss and muscle atrophy. The only risk is that too much weight-bearing too soon could compromise the fusion of the bones. I will have to be very vigilant in my weight-bearing progression.

At the moment, I am recovering in my moon boot. It is great to be able to take my boot off to shower or sleep. This whole Lisfranc thing has been a 3 1/2 year deal. Hopefully, I am careful and my fusion heals well. I don't ever want to go through this ordeal again. Five times is five times too many...

My dog Ruby, keeping me comapny.

Six months post fusion

I can hardly believe it has been six months since my fusion surgery of my first metatarsal, first cuneiform, and medial cuneiform. So far, it has been a journey with many ups and downs. Fortunately, there have been fewer downs than ups, which means the net effect has been progress. I am happy to say that my foot has not felt this good since before my whole Lisfranc fiasco - starting 3 years ago almost down to the day this entry is published.

I began a walking regimen, starting at 3.5 months post surgery (2.5 months ago, June 2017). My main goal was to first and foremost rehab my gait and learn to walk correctly. However, just as importantly, I wanted to slowly grease the gears of my muscles and tendons in my legs, ankles, and feet that hadn't been properly utilized in years. I think the best analogy to me getting moving again after my surgery would be like starting a 1960 Ford pickup that had been laying out in the yard for 30 years without being driven. Initially, with a new battery and an oil change, the truck may start up after a few cranks. After getting it started, you may be able to drive it around the block slowly with no problems. But once you take the truck out on the main road and drive it faster and for longer distances, all kinds of problems pop up: oil leaks, stiff suspension, the radiator needs to be replaced, the transmission needs a flush, the belt fan breaks, the brakes are shot, etc... If I haven't lost you, just replace all the problems that arise when driving an old truck with the maladies that I experienced when I started walking again. 

Aches, pains, and swelling - not limited to my feet - all graced me with their presence in strange and often confusing ways. One week it was a soreness/pain along my ankle and the next week it was a soreness/pain on the side of my arch. At some points, I thought I had hurt myself by pushing it too much only to be surprised the next day when the pain or soreness had disappeared. I have struggled with plantar fasciitis and posterior tibial tendonitis on and off for the past 2.5 months. Right now I have a nagging case of tendonitis on my right leg - not even the side that I had surgery on 6 months ago - that has popped up for reasons I can't explain. I am not even partaking in high impact sports or running of any sort... So goes the mystery of the adjusting body.

Nearly 3 months into my walking regimen I have worked my way to walking 2 miles 3-4 times a week. To give some perspective, when I started I walked 1/4 miles at a crawl. I slowly worked on more distance week by week. Additionally, I worked on my stride and walking speed. Now I can walk just as fast a normal person. Between walking, I also did other strengthening exercises to rehab my legs, feet, and overall body including swimming, weight training, and stationary biking.

I have recently been doing a little hiking. Nothing too impressive but nonetheless something I haven't been able to do in years. I first started hiking a one-mile path up a small mountain close to home, and then I progressed to a two-mile hike up a more demanding mountain in the Blue Ridge. Besides the pesky posterior tendonitis in my right leg, my feet felt fine and the hike was good. Below is a picture I took from the top of the mountain.

Threshold

It has been 14 weeks since my fusion surgery of my first metatarsal-cuneiform and first cuneiform-second cuneiform in my left foot. My last post detailed my progress weight bearing in a boot. In total, I spent 6 weeks in a boot. The first 2-3 weeks of which were filled with ups and downs related to pain, soreness, and stiffness in my foot and ankle. However, I was usually able to abate any pain or swelling with icing and rest. After about 3 weeks in the boot, most of the kinks were worked out and my foot and ankle were fine.

Having gone through this charade before, I was relatively happy with the progress of my foot while in a boot. I have slowly regained mobility and strength in my foot and ankle, which was nearly nil directly after my NWB cast was removed. The new found mobility that the boot afforded me was better than the best Christmas gift I ever received. My mobility gave me the freedom and independence that had been shying away from me for the 5 months I have been dealing with this particular foot problem. Because of this, my general mood and motivation have improved significantly.

Oblique X-ray showing my hardware and signs of fusion
of the 1st TMT joint.

Now after 6 weeks in a boot, it is finally time to approach the threshold moment in recovery - shed the moon shoe to make one more small step towards healing. This brings us up to speed with my progress as of today. This morning I went to the doctor and was cleared - after standing weight-bearing X-rays were analyzed - to transition to walking in a normal shoe. As in any step in this recovery, I will have to work out a few kinks before this next stage of freedom is complete. I imagine I will experience some pain, swelling, and soreness in the weeks to come as I wean myself off of the boot and mature to a shoe. Most importantly, I will have to listen to my body, more specifically my foot, in this next stage. As long as I feel I am making progress, I will be happy.

My cat sniffing my newly freed foot. I would guess it didn't
smell like roses.

Today marks 6 months since I last stood on the ground with both feet sans boot, crutches, or knee scooter. The mere fact that I can possibly walk unencumbered with my two feet makes me extremely happy but also anxious. Since I have gone through this terribleness - in some regard or another - four times previous, I cannot help but have thoughts of my foot somehow becoming hurt again. I do my best to assuage and process these feelings so that I am able to stay positive and look forward. For any of you veteran Lisfrancer's or the unfortunate newly indicted members that are reading this, you probably have some sense of this. It has been a long and arduous road and I am still on it. Patience is key. But I sincerely hope I am leaving behind an unfortunate period and moving on to better times - at least in regard to my feet.

For anyone with questions regarding Lisfranc injuries, treatment options, and recovery please feel free to ask any question you have. I don't claim to be all knowing about this type of injury - and as I have stated many times previous every Lisfranc injury is different - but I have a large amount of knowledge through experience and research on the subject. Today marks 3 years that I have been dealing with this injury. As far as doctors, treatments, and recoveries I have been through the gambit. I would love to use these otherwise useless credentials to help others because I know how frightening it is to not know. I can't put these things on my resume so I might as well use them somehow...

Pictures of animals always make things better.
Here my cat looks like a pear.

The Afterburners

It has been 10 weeks post fusion surgery on my left foot. I have spent the last two weeks transitioning from non-weight bearing in a hard cast to partial weight bearing with a boot. Honestly, it has been a slow go, but I have been making progress, which is all I am worried about. At the moment, I have graduated from partial weight bearing with two crutches and a boot to partial weight bearing and one crutch and a boot. Little by little I have put more pressure on my foot over the course of 14 days. This has ensured that I not only decrease the risk of injury, but I also build up stamina and strength in my foot. In effect, this type of transition lowers the amount of pain I experience each day. My foot is fairly swollen and sometimes sore or painful in the evening or after a day of greater exertion on my foot. However, the swelling and pain have been decreasing quite consistently with each passing day (hopefully I don't jinx myself).  

Dorsal X-ray of left foot 8
weeks post fusion surgery.

The biggest fear I had through this process is that my joints would not fuse properly. Nevertheless, I have been reassured by my doctor that the X-rays show good signs of a proper fusion. The progression to "walking" is a big step in any recovery of this nature. My spirits are definitely higher with my two legged - although still somewhat constrained - freedom. Being that this is my 5th surgery on my feet in less that a year and a half, I really hope that it was my last. As anyone who has gone through a Lisfranc injury and subsequent surgery can attest, it is overwhelming and painful - both physically and mentally. Psychological integrity is imperative to push through these types of injuries and recovery. In truth, mine has been tested beyond anything I ever imagined and worn down to the point of being nearly broken. I hope I emerge from this in a healthy state. 

When I first found out I had a Lisfranc injury, I scoured the internet to find others with similar injuries. I wanted to learn my options as well as the outcomes. For those who are now just discovering they have a Lisfranc injury and all the horrible anxiety that comes with it, I hope that you find this blog helpful. I tell almost everyone that has a Lisfranc injury and is looking for answers that every Lisfranc injury and recovery is different. Do not go looking for specifics. It should never be expected that one person's experiences - whether positive or negative - are transferrable to your own situation. But, it is useful to be knowledgeable about Lisfranc injuries, how others were treated, and the possible outcomes of each type of treatment. I hope that one day I will be walking around on two feet again in relative painlessness. Until then, I have to put on the afterburners and keep on truckin'.

Science has proven that looking at pictures of dogs and cats can lower one's stress levels and blood pressure... So in closing, here are some pictures of my cat:

Out of the fire and into the frying pan

When I was in the cast. Foot is resting on my knee scooter
(best investment I made).

     It has been about 8 weeks since I last posted. At the time, I had just undergone fusion surgery on my left foot. Two weeks post-op my surgical splint was removed, X-rays were taken to ensure hardware was in place, and sutures were removed from the surgical incision. X-rays and incision all looked good. After the splint was removed, I was placed in a non-weight bearing hard cast, which I wore for 6 weeks. Life in a cast was frustrating, boring, and slow. I had a knee scooter for getting around the house easily. I learned from previous surgeries on my foot that freeing up my hands - which crutches do not allow - with the knee scooter enabled me to be considerably more independent. The only times I used crutches were if I went out of the house with my family or to see a friend. 

     Now almost two months after my operation, I have finally been removed from my non-weight bearing duties in the hard cast, and I have been transferred into a walking boot. This doesn't necessarily mean that life is any easier now. Putting pressure on my foot for the first time - even in a boot - is a painful process. In addition, I have to learn how to walk again. I am actually slower at getting around now than when I was in a cast. Nonetheless, I have been happy to walk (although very slowly) on two-ish feet. The transfer into a boot is a slow process, and I know it will take days if not a week or two for me to be relatively comfortable walking in the boot. I got to get the gears greased and cranking again.

The cast is off and into the boot. Had to include a picture of
the incision.

In the meantime, my cat (Luna) has been keeping me company and I have added a few more books to my completed reading list.

1. Unbroken: A World War II Story of Survival, Resilience, and Redemption - Laura Hillenbrand

2. Stiff: The Curious Lives of Human Cadavers: Mary Roach

3. Tuesdays With Morrie: An Old Man, a young Man, and Life's Greatest Lesson

4. Hiroshima: John Hershey

Luna in loaf mode