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.


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