Sunday, March 31, 2013

Days 4 & 5 Post Surgery - NYC Cab drivers suck

March 30, 2013 & March 31, 2012 " NYC Cabbies don't seem to have any love for a guy on a scooter with a cast on his leg" Summary - Went to NJ for a fantasy baseball draft on 3/30/13. Felt pretty good except for motion sickness/nausea while in a car - Fever gone; antibiotics working. Sinus infection still very severe with a ton of blood/puss still around, but headaches aren't quite as severe and I'm not quite as congestion. - 5 different cab drivers refused to pick me up from Penn Station as a passenger. They saw me on my scooter and tried to avoid me. I had words with a few of them. For the first time in my life, I can truly understand how tough it is to get around as a "handicapped" person and how they are discriminated against. - Went to Queens to visit Lola Linda with the family, who has been sick but is getting better. Car ride was ok. - My foot/ankle pain was noticeably less today. I took some pain medicine in the evening, but didn't need it until then. I took a long 2+ hour nap in Queens, so I'm definitely still feeling the impact of my sinus infection - My right shin bone below the knee continues to be sore. I think this is because of the pressure being put on the leg on the scooter. In the past, I once had a stress reaction in this area (comes before a stress fracture, which I never had there). I need to keep an eye on this pain so it doesn't turn into an injury - I notice that my legs/IT bands/glutes are a little sore from all of the exercise my legs are getting. Need to keep an eye on this also. Overall, I'm very pleased where I am at. Going to take it easy for a few more days and then think about when I can go back to work.

Day 3 post surgery - 3/29/13

Generally, foot is feeling a little better than yesterday, although as the numbness in the foot and leg wanes, I have had high levels of pain and nausea and taken pain medicine accordingly.

Mikayla, Kaiya, and I took my mom to urgent care because she had a fever (101.5) for the last 36 hours or so. We thought it was smart for my mom to go in given that Kaiya has the flu, walking pneumonia, and pink eye and is on tamiflu, Zithromax, and Vigamox eye drops, I have a severe sinus infection and pink eye and am on Augmentin and Vigamox eye drops, and Lola Linda is super sick too. This was my mom's first visit to a doctor since 1994. The doctor said that her ears, lungs, and mouth all looked good but that her fever of 101.5 is high for her age (69), as our fever levels should be lower as we get older. So, the so doctor prescribed tamiflu and cough syrup.

My fever was gone almost all day today, which was great.

I scooted around again today, and yesterday I scootered all the way home from my doctor's office (about 3 miles). I wasn't planning on doing this but I got dropped off and forgot my wallet. Being in a wheelchair in NYC must be tough...the sidewalks are very rough and so are the ramps (when they exist at all).

I took my first shower since the surgery today. I put a chair in the bathtub and another chair to hang my right leg outside the tub. I purchased a long plastic cover to put over and protect my cast, and it worked really well. I never turned on the shower. Instead, I used a large Tupperware container and filled it up with water, poured it over my body, and repeated. This allowed me to go nice and slow to be safe. Ideally, I would have a sprayer coming out of the faucet so i wouldn't have to refill the Tupperware. I will look into this.

Thursday, March 28, 2013

Days 1 and 2 post surgery.

I received my new toy today, a scooter that allows me to put my knee up and cruise around. My doctor highly recommended it and I love it! It is so much better than using crutches.

Here are a few videos:

Day 1 post surgery (3/27/13)
Felt ok throughout the day. The numbing blocks in my leg were slowly wearing off and I could feel and move my toes today, something I couldn't do yesterday. As the numbing wore away, my pain level was around 9-10 for a while. I took some pain meds and this helped a little, taking the pain level down to 5-6. Yesterday I had some nausea, but none today.

In the evening I started to feel hot. So I checked my temperature and it was 102.8! I also had the chills. The doctor told me that it isn't uncommon for people to have a fever after major surgery. We called him at 130am and he told me to come in to see him the next day if I still had the fever. The fever hovered between 101.5 and 102.8 for the rest of the night.

The best part of my day was when my daughter Mikayla (6) made me a few cards (pictures attached).

Day 2 post surgery (3/28/13)
Fever hovered around 100.8 - 101.5 in the morning. Saw Dr Elliot around 130pm and he and his resident took off my cast to make sure that I didn't have an infection. Quite the contrary, no infection and the foot/ankle looked great (see the attached picture). The doctor said that I was doing a great job at keeping it elevated, which helps keep the swelling down. He told me that my Brevis tendon looked "very sick, was split in places, and must have been very painful." He said, you absolutely did the right thing by having the surgery. I expected my foot/ankle to be very swollen post surgery based upon the research I did. I was extremely encouraged by a low swelling level thus far.

I asked him if he thought I could walk, not run, this year's NYC Marathon, which is about 7 months away. He said "maybe", let's see how you progress, but this might be aggressive. I like to have goals, and one of them is to run the NYC Marathon every year, even if I need to walk it.

After I saw Dr. Elliott, I went to see Dr. Saha. He took my temp (100.5), bp (122/78), and put some tubes down my nose. He said I have a severe sinus infection with tons of puss. He said that if my fever goes up anymore I should go to the emergency room, as he was concerned that the infection is so bad that it might carry over to the brain. I'll watch out for it. So, I'll be taking Augmentin, a very strong antibiotic, twice a day for 14 days.

Wednesday, March 27, 2013

Right foot/ankle surgery

3/26/13 -

Day 1 - Surgery Day - No weight bearing allowed on my right leg for 6-8 weeks, on crutches

Today I had reconstructive foot/ankle surgery to repair my nearly completely torn/frayed peroneal Brevis tendon at the Hospital for Special Surgery "HSS". I had both a tendon transfer from the peroneal longus tendon to the peroneal brevis tendon as well as a calcaneal ostemy. I tore the brevis tendon over 20 years ago and lately I had pain so it needed to be fixed. I was told 20+ years ago that I needed surgery, so I made it pretty long before having it fixed.

I arrived at the hospital at 6am and the surgery started around 830am.

The surgery was per performed by Dr. Andrew Eilliot, who is a specialist in the foot, ankle, and orthotics. I really like him because he takes the time to explain things to me, particularly about how my arch and heel mis-alignment is something that I was born with and that if I just fixed my peroneal Brevis tendon without fixing my arch/heel mis-alignment, I would once again tear my peroneal Brevis tendon because this mis-alignment pulls at the tendon upon every step (even walking). He said that he sees this frequently after a patient has only the tendon surgery somewhere else. He said that also getting the calcaneal ostemy done would give my new peroneal tendon transfer the best chance to live/survive another 50 years. That is why I decided to get both surgeries done. Without them, he said that I shouldn't run anymore or do weight bearing sports, because I will likely tear the tendon completely and fray it from 5-10% left to zero. He also said that the peroneal longus tendon "is also stating to fray, which means if you keep running without surgery, you will tear/fray this tendon too, then you will definitely not be able to run again. Ever.". So the surgery, for me, was the only way to go. Not being able to run or do other weight bearing sports (like basketball) just isn't an option for me. Period.

Surgery went well. I received a spinal epidural for the procedure. The same epidural that women receive when having a baby!

The doctor said that the tendon was "really really bad, basically gone". They did a tendon transfer and broke my heel to move it over and then put two pins in it.

They also have numbed my leg from above the knee down for a few days, so the pain is moderate now but is projected to be severe in a few days. Pain meds, 2-4 mg of dilaudid are available for me to consume if needed.

Procedure - Given spinal epidural, some versaid, 12.5mg of Benadryl (to combat my soy allergy), and 20 of propapol. Was totally asleep the entire surgery, where they performed a peroneal Brevis tendon transfer and a calcaneal ostemy to break my heel, move it over, and insert 2 large screws into the heel so it grows back together in this new position. Also took additional versaid and other drugs as needed during the procedure to remain "comfortable"

After surgery I ate a ton of fruit and drank a cranberry juice that I later determined had high fructose syrup in it, something I no longer consume. Bummer. My wife was there which was totally awesome. She took notes, because I couldn't remember anything the doctors told me after the surgery, I guess due to being still heavily sedated.

After the surgery had 2 Percocet and 0.5mg of dillaudid (IV) for the odd feeling of numbness in my foot

Discharged from hospital around 2pm. HSS is amazing. Extremely well run, everybody knows what they are doing and are efficient. They are helpful and made me feel very comfortable the whole way through.

When I got home, my kids Mikayla and Kaiya gave me a great welcome home by decorating the entire living room with colorful stickies.

All day and evening, I was unable to feel anything from about 1/2 inch above my knee down to my toes

Had mild Nausea in the afternoon

Drank a green machine smoothie I made in my vitamix blender the day before (kale, spinach, broccoli, peas, 1 large mushroom, baby carrots, apples, banana, pineapple, dates, water, and ice. I follow a plant-based (vegan) diet, which I strongly hope (believe) will speed up my recovery, particularly on the swelling side. .

Around 9pm took 2 Percocet for what felt like shin splints halfway up my right leg. I have a history of shin splints in this location, not sure why it was flaring up tonight.

Kept my foot elevated all day and evening. Slept on my back with my foot elevated all night. A little awkward as I normally sleep in my stomach, but not bad.

It was great having my mom in town from Wisconsin to help me out. We watched the first and part of the second episode of "House of Cards" in Netflix. I find it to be even better the second time (her first time).

Food/Weight tracking.
I plan on tracking my food and basic nutrients consumption as well as my weight for the next few months, as I basically can't exercise for the next 3 months. Will be interesting to see what happens, as I am used to exercising every day.

I weighed 180.1 pounds the morning of the surgery (using a Withings wireless scale which we find very reliable and beams right to my iphone and the web) and, according to my calorie/nutrient tracking, consumed 1923 calories today, as follows:

Breakfast - nothing consumed, not allowed to eat/drink anything after 5am.

Lunch - a can of cranberry juice and a bunch of fresh fruit provided by HSS, which was impressive that they could provide - grapes, banana, baby tomatoes, honeydew, cantelope, pineapple, and blueberries.
642 calories / 9g protein

Late lunch
Green machine - 352 calories / 11g protein

Dinner (appetite still low)
2 bananas/1.5 cups of fresh blueberries. 334 calories, 4g protein

Late dinner
2 cups of salted almonds, 3/8 pint of So Delicious cherry amaretto coconut ice cream. 595 calories / 14 protein

1923 calories (goal 2,000)
38g protein (goal 50, I usually consume 70-100 grams a day but was much less today due to not eating until lunch.

46g fiber (vs 25 or higher goal)
O cholesterol (vs FDA goal of 300)
Sodium 446g (vs FDA goal of 2400)
Sugars 204g (vs FDA goal of 50) - I strive to only consume natural sugars contained in fruits/vegatables and am regularly much higher the 50g, which is ok with me because it is all natural sugars. I don't agree with those who say that fruit in sugars is bad. I believe that we can't overdose on fruit (and my bloodwork confirms this)
Carbs - 371g (vs 300) - always high due to high fruit consumption
Fat 48g (vs 65)
Saturated fat 15g (vs 20) - I regularly run over 20 as many of the foods I consume are high in "good fats" - avocados, coconut, nuts, etc

Monday, March 25, 2013

How I went from 100% healthy to a Peroneal Brevis tendon tear to surgery

This is a summary of how I went from what I thought was 100% healthy to having major reconstructive foot and ankle surgery, all within about 7 weeks.  I was misdiagnosed by both a radiologist (said my peroneal brevis tendon was normal when in fact it was completely ruptured/torn and nearly completely gone) and by a doctor who said my peroneal brevis tendon was normal (in response to my question "how do my peroneal brevis and longus tendons look on the MRI?)."  I knew something was wrong and didn't settle until I was properly diagnosed.  If there is one thing I have learned in my life is that one has to take care of their health by being educated and proactive.


On February 3, 2013, I ran a 50 mile trail race outside of Houston, Texas called the Rocky Raccoon 50.  I had no pain in my foot or ankle during the race.  6 days later, I went for a run and an area around my ankle hurt.  It felt like a sprained ankle without having sprained my ankle (although during the 50 mile race I turned my ankle a few times, something that happens to me frequently but usually doesn't result in swelling, with the exception of the 2010 NYC marathon, where I rolled my ankle and it was hugely swollen immediately and for the last 7 miles of the marathon).  When I turned it during the 50 mile race, it didn't get swollen and I didn't think about it again until now.  I looked online and determined that the area of my pain was in the peroneal longus tendon area. My friend Justin also did some research for me and came to the same conclusion.   I'd never heard of this tendon before.

Over the course of my life, I've always had "weak ankles".  I could never ice skate comfortably because I never felt like the ice skates supported my ankles.  In college, I played basketball everyday (sometimes twice a day), and I frequently sprained my ankle, sometimes severely.  One time I even sprained my ankle in a pothole walking down the street (actually my worst sprain).  The pain/swelling in my foot during my sprains was usually worse than the pain around the ankle.   I was on crutches 4 or 5 times while in college and once or twice while living in NYC.  Doctors told me in college that I likely tore major ligaments and tendons and that it would have been better to break my ankle than to tear the ligaments/tendons, which I would likely need surgery to repair someday. I never had an MRI of my foot or ankle to determine the damage.  I wasn't an endurance athlete at this point so I just stopped playing basketball until it felt better and then wore ankle braces or taped my ankles when playing.

So,the week after my 50 mile race the pain in my peroneal longus area was severe enough that I decided to go to a doctor.  On Saturday 2/25/13 I went to the neighborhood urgent care where they took an xray, which showed arthritis but no breaks.  So the urgent care doctor was able to refer me to Lenox Hill radiology for an ankle MRI on the same date, saying "rule out tendon injury".  The Lenox Hill MRI concluded the following:

1.  Plantar fasciitis with prominent plantar heel spur and associated localized stress related marrow edema. - no surprise, I struggle with this sometimes.
2.  Chronic tear of the ATFL with scarring at the anterior lateral gutter.  - no surprise
3.  Mild tendinosis and tenosynovitis of the peroneus longus proximal to the level of the cuboid tunnel.   - new, although much more painful than "mild"
4.  Minimal ankle and posterior subtalar synovitis. - not a surprise

It also said "The flexor, extensor, peroneus brevis, and Achilles tendons appear normal in contour, caliber, and signal."

So, next I emailed my shoulder/knee doctor (Riley Williams, HSS) for a referral to a foot/ankle doctor at HSS and he recommended Dr. Andrew Elliot.  So, I called Dr. Elliot on 2/28 and the earliest appointment he had was in May.  May?  No good.   My pain level was such that I thought I might need to be in a boot.  So, my urgent care doctor (Dr. Neal Shipley, good guy, very helpful) referred me to Dr. Joseph M. Bellapianta, a foot/ankle/shoulder/knee doctor on East 92nd street.  I told Dr. Bellapianta about my history and asked him if he could read the MRI because it seems to be wrong to me based on my pain level.  Specifically, I said "can you please take a look at my MRI to see if you agree with the report's conclusions?"  He said that he did look at it but "I care much more about how you are feeling and your symptoms.  I don't want to do surgery if you don't need it".  Seemed to me like he is a doctor (young) that wants to treat people conservatively before considering surgery.  This is ok with me but I found it to be extremely disappointing that he either (1) couldn't read my MRI properly to diagnose my torn peroneal brevis tendon, particularly when I asked him to do so and/or (2) he actually didn't read it but told me he did.  Very unimpressive.

So, now more than ever, I knew that I needed to see Dr. Elliot, so like Bud Fox called Gordon Gekko everyday on the movie Wall Street to get a meeting with him, I called Dr. Elliot's office every day (often multiple times a day) basically begging for them to squeeze me in.  Finally, a week or so later they got me in. 

So the first thing Dr. Elliot said to me at my appointment was "come here Jim, I want to show you something".  He took me to a computer screen where he showed me my MRI images.  I didn't have to ask him to read my MRI, he just did it (unlike Dr. Bellapianta).  He said "your MRI report says that your peroneal brevis tendon is normal, but I don't even see your brevis tendon.  I think your MRI report is wrong and that you have ruptured your tendon.  If this is the case, you will need to have surgery to fix this tendon if you want to run again." He said "I want you to go to the HSS radiology department to get an ultrasound on your foot and ankle so they can see what your peroneal brevis tendon looks like".  So, 30 minutes later, I had the ultrasound and the first thing the Dr. Gregory Saboeiro said was "uh oh, that tendon isn't supposed to be up against the bone like that".  Basically, he said that only a very small amount of the peroneal brevis tendon remained (no more than 10-15%).  His report said that I had a "high grade (means >50% tear) but incomplete tear of the right peroneus brevis with some slender intact fibers and that the peroneal longus demonstrates moderate tendinosis without tear".  I told him that I recently received an MRI at Lenox Hill that report said that my peroneal brevis tendon was normal.  I asked him if he wanted to see the report written by Hilary Umans, MD and he said absolutely.  So I handed it to him.  Frankly, he was shocked that somebody could read the MRI as having a normal peroneal brevis tendon (and Dr. Elliot was as equally surprised).  Dr. Saboeiro said that Dr. Umans (the radiologist at Lenox Hill that misread the MRI) used to work at HSS and that he would follow up with her, but I don't know if he ever did.  The wrong Lenox Hill report is very disturbing.  What if I hadn't gotten the second opinion from Dr. Elliot?  I likely would have continued to run, which according to Dr. Elliot would have eventually resulted in the complete tear of the brevis tendon, which may have resulted in me never being able to run again.  When I had the MRI done at Lenox hill, there had to be at least 25 people in the waiting room getting tests one (on a Saturday afternoon, nonetheless).  I feel like these MRI facilities shuttle people in and out quickly and as a result the radiologists need to rush their reports to keep up.  The more reports they read, the more money they make.  As an aside, I called Lenox Hill after I got the ultrasound to let them know that there was an error in my MRI report and that I'd like them to re-issue my MRI, but the supervisor in charge of dealing with the reports never returned my call.  I need to follow back up.

One of the things I read about Dr. Elliot is that he does a great job of explaining things, including why injuries happen and how they should be fixed.  Very true.  After examining my feet, the first thing he said to me was "let me see your orthotics".  I said "Soris made them for me" and handed them to Dr. Elliot (I had no idea whether Dr. Elliot would know who Soris is).  If you've read my blog in the past, you'll remember that I LOVE Soris.  She is an expert in orthotics and fits professional athletes and Olympians.  I became a lot healthier once I started wearing her custom made orthotics.  So, Dr. Elliot examined my orthotics and said that I was one of the few people he has seen that is actually in the correct orthotics for my condition.  My condition, I asked?  What condition?  He explained that I was born with anatomically mis-aligned feet and heels, which, he said was causing my "weak ankles", as the mis-alignment means that every step I take (even walking) pulls on my tendons, causing my tendon tears, fraying, and ankle sprains  over the years.   As an aside, Dr. Elliot, who specializes in orthotics, refers all of his patients to Soris.  I asked if my endurance activities were the cause and he said "no, your heel mis-alignment and high arches are the were destined to have this happen to you at some point even if you weren't an endurance athlete, although the endurance activities may have sped it up a little bit".

Dr. Elliot's recommendation was for me to have surgery to transfer the peroneal longus tendon to the brevis tendon and to have a calcaneal ostemy, which basically breaks my heel and moves it to the correct position (with screws put in to help the heel grow/fuse into a better position).  He said that most doctors would only do surgery to fix the tendon(s), and that very often the patients that had the surgery on the tendon with another doctor come to see him after that patient re-tears the tendons that were fixed.  He explained that happens because the true problem wasn't fixed - that being the heel mis-alignment (and for my very high arches) still causes the tendon to be pulled on.  He said that if I have the heel moved over, then "that gives your tendon the best possible chance to last another 50 years".

So, I did a lot of research and so did my friend Justin.  Everything we read for a brevis tendon tear as severe as mine said surgery was needed.  Physical therapy can't heal a tendon that isn't there anymore. 

I decided to get one more opinion, that of Soris Tribino.  When Soris first met me, she was able to diagnose my problems just by looking at my feet and by watching me walk.  According to Dr. Elliot, her orthotics helped significantly slow down the progression of damage to my tendons.  When I told her about my brevis tear and Dr. Elliot's recommendations to fix it and get the calcaneal ostemy, she told me that Dr. Elliot is a great surgeon and that I should have it all done.  Sold!  I decided to get it done.