Wednesday, May 16, 2018

Peroneal tendon rupture, surgery, and rehab, part 2

It has only been two months since my post about part 1, and already it feels like several lifetimes have gone by...

Lifetime 1:  visit with surgeon #2 and improvements

Surgeon #2 was excellent and it was well worth going.  For a start, he gave me 15 minutes of uninterrupted appointment time, practically a miracle compared to my experience with surgeon #1.  Surgeon #2 was concerned about the fact that surgeon #1 had placed a tenodesis anchor right on the site of my metatarsal fracture and thought that might be the cause of all the pain.  He did an x-ray to check that the anchor hadn't caused the fracture to re-open, which fortunately showed that it hadn't, although it could still have been causing the pain.  However, surgeon #2 also did an ultrasound, which did show a large bone fragment stuck right next to the tendon repair, making it a prime candidate as a pain cause. 

The next month was full of slow, steady improvements.  Of course, there were plenty of "bad foot" days, and I still suffered from perma-red foot from all the inflammation, but it was definitely an upward trend.


The mental crux that I hadn't been expecting was the time period where I was able to walk but not yet able to walk far enough or fast enough to get any aerobic exercise.  As depressing as it was, I had to resign myself to going out on the crutches or the pegleg for the "exercise" portion of my activities, and then practice walking separately.


Somewhat ironically, I got less and less fit aerobically as my foot improved, since I started doing more walking and stopped doing my uphill crutching repeats!

Finally, at 13 weeks post-op, I did my first outing that could, if you were feeling unusually optimistic, be called a run:  5 miles on a vertical k course, mostly walking the steep uphill, running the gradual uphill, and running nearly all of the downhill.

Lifetime 2:  infection

The improvements came crashing to a halt when my surgical wound got infected at 13.5 weeks post-op.  An infection that shows up that late in the game is a very worrying thing, since it makes it highly likely that the infection is a deep one.  Cue total rest, elevating my leg, hours of frantic research and quality advice from the most qualified medic I know, and a trip to the doctor, who prescribed antibiotics and never managed to answer my question about when I should come for follow-up care if the infection didn't clear. 

It didn't clear.  After 5 days of antibiotics and no improvements, I sent a panicked email to surgeon #2, who was kind enough to look at a few photos of my foot and then told me to get it seen sooner rather than later.  Two days later, I was in surgeon #2's office.  He did an ultrasound to check if it might be a stitch abscess (it wasn't) and then confirmed what I had already suspected from my reading:  the doctor I had seen a week ago had prescribed an incorrect choice of antibiotic.  So I moved on to antibiotics round 2, took a deep breath, and talked myself into handling the mental pain of going back on crutches for exercising.

I'm not wearing the orthopedic boot because I need it for walking, I'm wearing it to prevent walking.  It's the runner equivalent of the cone of shame.

It's funny looking back on my changes in perspective since the injury.  When the accident happened on December 2, my first thought was "will I have enough time to train for Transgrancanaria?"  TGC is in late February!  After finding out I needed surgery and then getting delayed for a couple of months on that, my worry was whether or not I'd be able to race this summer.  After finding out I had been robbed of a key foot tendon whilst unconscious during surgery, I was concerned about whether I'd ever run on technical ground again.  And by late April, with a late-onset surgical site infection, I was ready to consider it a win if I didn't have to have my foot amputated.

Luckily for the chances of continued attachment of my foot, the second round of antibiotics worked, but...

Lifetime 3:  sural nerve issues

...getting rid of the infection did nothing to change the unbearable level of pain I'd been experiencing.  Neither did two weeks of total rest, so it was clear it wasn't a simple case of overdoing it on the newly-repaired tendon.  The type of pain--white-hot, coming and going in flashes--didn't feel like tendon pain, either, and I did more reading and starting thinking it could either be an allergic reaction to the biocomposite material in the tenodesis anchor (shows up, if it's going to happen, when the anchor starts to degrade around 3 months post-op, so the timing fit, plus the inflammation seemed to respond a bit to an antihistamine) or damage to the sural nerve. 

I finally deployed the weapon I should have deployed two weeks earlier:  a visit to my amazing physio.  He was almost sure the problem was with the sural nerve; it runs alongside the peroneal tendons and it's common for it to get damaged or entrapped in scar tissue after peroneal tendon surgery.  I left after an hour of serious poking and prodding to try to extricate the nerve, with instructions to perform twice daily exercises and to wait at least 5 days before trying to run.

And today, 5 days later...I ran!  Four repeats of 5 minutes each, on very flat and soft ground.  There was still definitely nerve pain going on but at a much more manageable level than before.  It's a start...



 

Thursday, March 8, 2018

Is it May yet? Peroneal tendon rupture, surgery, and rehab, part 1

Opening up my blog to start this post made me notice that my last post was about a medical problem.  I guess this is fairly appropriate--my year was largely a sequence of lurching from one problem to the next, with a few nice runs and climbs in between.  If things don't improve soon, I'll rename the blog something like aliciasrestingandrehabilitationwoes.

The closest I'll get to running Zegama this year

At the end of a great long run in the mountains, I was running down a moderately technical descent when I landed badly and injured my foot.  I heard a loud cracking noise so was fairly sure there was a broken bone.  I limped off the hill, hitchhiked back to my car, and drove straight to the hospital.  This was the start of a cascade of comedy errors that leads to my current situation.

The emergency room doctor took an x-ray and reported that I had a broken 5th metatarsal.  She thought it was a Jones fracture and thus might need surgery, so she told me to see a specialist.  This was incorrect--it was a fracture to the base of the metatarsal and not a Jones fracture--but her mistake turned out to be lucky for me.  The surgeon who I went to see about the fracture was able to tell immediately that it wouldn't need surgery, but fortunately for me, he noticed that I seemed to be missing my peroneus brevis tendon.  After multiple errors with the MRIs and an inexplicable order for a second x-ray, and thus plenty of delay, it was determined that I had a complete rupture of the peroneus brevis at the point where it inserts into the 5th metatarsal.

This could only be fixed with surgery, but there were an endless number of delays to getting a surgery date, and I finally went for the operation 7 weeks later.  By that point the metatarsal fracture seemed to be healed and I had been able to walk a little, but I had been on crutches 95% of the previous 7 weeks.  That meant my peroneus brevis stump had had 7 weeks to retract and atrophy.  Sure enough, my surgeon reported after the surgery that there was hardly any of it left.



What he didn't report was that he had done an entirely different repair technique than what it appeared he had been planning.  I learned from my hospital discharge form that what he did was tenodesis--sewing the peroneus brevis stump to the peroneus longus tendon--whereas I was under the impression he would be doing an allograft (cadaver tendon) repair.  It appears that this type of tenodesis is a common way of dealing with a lack of intact tendon to work with, so I can see why he would have done that.  However, I had made it abundantly clear to him that I was a competitive runner, that I ran in the mountains and needed maximum ankle stability, and that my priority was getting back to this.  Tenodesis is not at all ideal for any of these things (I believe you can read a good article about different repair options here without a paywall, http://www.foot.theclinics.com/article/S1083-7515(13)00104-6/pdf) so I was not particularly pleased, to say the least.  If my surgeon had been experienced at treating athletes, I could feel confident that he had correctly weighed the pros and cons of each option in deciding what to do.  However, it was clear from our pre-surgery conversation that he had little experience with athletes.  At the time, I thought this was okay because there was no question of what needed to be done; all I really needed was an experienced surgeon who could do the repair well.  It simply never occurred to me that this particular type of problem ("two tendons enter, one tendon leave"...?) might occur.  It was also clear from pre-surgery appointments that my surgeon was very interested in seeing the maximum number of patients possible, and this does suggest he may have chosen tenodesis on the basis that it's a much simpler and thus quicker procedure.

Frankenfoot, about 5 days post-op

After the surgery, I wasn't about to waste my time and money on more rushed, interrupted appointments with my surgeon (his appointments are 3 minutes long and mostly involve him talking to his assistants), so I took advantage of a friend's student status and downloaded all the relevant rehab articles listed in this review, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823352/.  It immediately became clear that there is a vast range of opinions from surgeons on the appropriate rehab program for this surgery.  Everything from immediate weight bearing to 8 weeks in a cast was on the table!  I went with a protocol that fell in the middle of the options, which was:

--2 weeks in hard splint
--Staples out at 2 weeks
       --If you're having this surgery done:  ask for stitches rather than staples!!  I would say as much
         as 50% of my pain in those first two weeks was from the lovely feeling that is 26 bits of metal
        digging into the area around a recent stab wound.
--Dorsiflexion/plantar flexion stretching exercises starting at 2 weeks
--Partial weight bearing in a walker boot from 2.5 weeks, starting VERY lightly with just a few toes on the floor and progressing extremely gradually as tolerated
--Full weight bearing when tolerated
--Standard physical therapy range of motion and strengthening exercises starting from 6 weeks
--Running on an alter-G treadmill
--Back to regular running no earlier than 12 weeks but potentially more like 14-16
--Plenty of sleep
--Lots of protein and very little sugar (high glucose diet seems to impair tendon healing in rats, and it certainly won't hurt to try!  https://www.salk.at/DMS/41598_2017_Article_700_1920815.pdf)
--Restricted eating window and coconut oil to encourage BHB production, which may have an anti-inflammatory effect:  https://www.ncbi.nlm.nih.gov/pubmed/25686106/.  My hypothesis was that this would give me the benefits of a ketogenic diet without the increase in cortisol I would get if I actually went on a ketogenic diet.

This all went reasonably well for the first 5 weeks, with plenty of bad days mixed in but overall it was a steady upward trend.  I did have a deviation from the plan though:  my walker boot, which I had been using for the metatarsal fracture, was very painful for the newly-repaired tendon.  I experimented a bit and found that a compression sock + ankle brace + wide-foot running shoe + running insole actually felt much better and more stable than the boot, so I switched to that early in week 3.  This may or may not have been a mistake...

By early in week 4 I was walking with two crutches and with about 50% of normal weight on my injured foot.  Later in week 4 I progressed to walking with one crutch and felt strong enough to try a few steps unaided.  They felt fine, and I did maybe 20 steps in intervals of 5 at a time, although the next day my foot was quite sore so I went back to two crutches and tried to generally stay off my foot.

Then things took a turn for the worse.  Divesh and I were headed to India for a week, and my foot was not pleased with two days of crutching around airports and the long flight time.  When we got to India, I took a day completely off any weight-bearing.  On the second day, I went back to walking with two crutches--and it did not go well at all.  My foot developed a raw, stabbing pain that evening and it was so painful that I couldn't sleep through it.  The next day was about the same.  It eventually calmed down to a more manageable pain level, but something is clearly different than it was during the first 5 weeks.

And that is why this is only part 1...I'm currently booked in to see a different surgeon, one who has just had an impressive result with my runner friend Diana's complex ankle repair surgery, in a few days to discuss my options for where to go from here.  I'm interested to hear whether he thinks it's possible and/or worthwhile to reverse the tenodesis and repair with an autograft or allograft instead (so far I've had conflicting information on whether or not this is possible; a 2014 case report says it was done but a very experienced surgeon in this area discussed it with me via email and said he doesn't think it can be done).  I'm also obviously keen to hear what he thinks may have happened to the current repair and whether or not there's any way of determining in the near future if the repair failed.

For now I've bought a different style of walker boot and I'm back to almost zero weight bearing.  I'll write part 2 when I've got an idea of where I go from here!

Friday, July 14, 2017

And then there were two? Magnesium, cortisol, insomnia, and athletes

I have been having trouble sleeping.  I first had insomnia for 18 days in April.  It was the worst experience of my life with any kind of illness; the mental trauma of being utterly exhausted but unable to sleep, every single night without respite, was worse than anything I've ever experienced with physical injuries, including having to take 9 months off of running for an ankle injury.  So when the insomnia reappeared in late June, I knew I had to get it resolved as soon as possible.



Google searches for athletes' personal experiences with insomnia brought me the horror stories of Bobby Curtis and Tera Moody (don't click on those links if you think your insomnia might be made worse by anxiety about not sleeping!) but other than that, the sum total of anecdotal information was essentially a few forum posts by athletes saying they were having trouble sleeping and wondering if anyone else had had the same issue.  There were virtually never any real answers or any follow-up from the athletes themselves.  Relevant journal articles are out there, but they took a fair bit of time to collate into anything useful.

Given the difficulty I had finding information on the subject, I thought I'd provide some details on what happened with my insomnia and what I've learned along the way, in the hopes that this will be useful to someone else going through the same struggle.

My insomnia

I had what is apparently termed sleep maintenance insomnia.  I could fall asleep easily at bedtime but I would wake up about 4 hours later.  As the April period of insomnia wore on, this got worse and I started waking up only 2 to 3 hours after going to sleep.  When I woke up I would feel almost instantly wide awake and my heart rate would be racing.  If I managed to relax, I would sometimes start feeling sleepy again in about an hour, but absolutely nothing, including the sleeping pills that I eventually tried, would get me to actually fall back asleep.


Timeline

There is maybe no way to make this part *not* super boring, but I think a few things about the timing of the insomnia may be relevant, so here goes...

--April:  Training block with lots of hillwork in and around Atlanta. Mostly went really well.

April 4 and 5--training diary says I felt awful and took two days off

April 8--first night of insomnia, which would continue every night until April 26ish

April 8 and 9--did two hard runs; felt fine

April 9 to 21--ran very little as the insomnia got worse and worse

April 22--raced a hilly 50k

April 23--overseas flight

April 24--slept 7 hours (sleeping pill aided...) after being awake for 36 hours

April 26--first night of truly normal sleep

Month of May--normal sleep; bits of hard training in cooler climate interspersed with having a sinus infection and not being able to run

May 26--hard 24 hour run in the mountains

May 27 to June 23--sinus infection; didn't run at all except for a couple of 10-20 minute jogs

June 26--started training again with a VERY easy week, although I was in Atlanta and it was about 90 degrees every day.

June 30--first night of Round 2 insomnia

July 1 and 2--only managed 4 hours of sleep

July 3--started taking magnesium supplements (more info below); also stayed up all night to try to force better sleep the night after

July 4-6--normal sleep but took diphenhydramine at bedtime

July 7 and onwards (so far!)--basically normal sleep without any diphenhydramine, although I do still tend to wake up once for a couple of minutes in the middle of the night.


Treatments I tried on round 1 (April, 18 days til normal sleep returned)

In no particular order:

-No caffeine the entire period, including cutting out chocolate
-No computer use after dinner
-Blackout curtains for the bedroom
-After waking up in the middle of the night, getting out of bed and doing some mindless task.  Only worked once, on day 16.
-After waking up in the middle of the night, staying in bed and trying to relax, including listening to talks or meditation podcasts.  Never worked.
-Melatonin, which I had only used about twice in my life previously, both at bedtime and after waking up in the middle of the night.  This did actually work on one night--I woke up in the middle of the night, took 3(?) mg melatonin, and got back to sleep and slept for one hour after taking it.  It didn't work any of the other times I tried it.
-5-hydroxyryptophan at bedtime
-"Lightweight" sleeping pills with the antihistamine diphenhydramine, which is possibly not detrimental to sleep quality, after waking up in the middle of the night.  Made me extremely sleepy but I couldn't fall asleep.
-Days 12 and 13:  600mg of phosphatidyl serine (a phospholipid which potentially lowers cortisol) about an hour before bedtime.  Didn't work on either of these two nights.
-Days 14-18 and onward for another week:  300mg of phosphatidyl serine about an hour before bedtime; dosage lowered after I read a study suggesting any potential effect wouldn't happen if the dosage were too high.  Didn't help on days 14 to 18 but perhaps the cumulative effect of taking it since day 12 finally kicked in on day 18...??
-Days 14-18 and onward for another week:  200 to 300 mg per day of magnesium supplement in the form of a dimagnesium malate tablet.  Didn't help on days 14 to 18 but potential cumulative effect??


Treatments I tried on round 2 (June/July; 5 to 7 days til normal sleep returned)

-Starting on day 2, magnesium supplementation.  About 200mg a day of powdered magnesium citrate and another 200mg of dimagnesium malate tablet (hedging my bets!)
-Also starting on day 2, 300mg of phosphatidyl serine one hour before bedtime

I should also say, I didn't cut back on running at all during round 2.  In fact I increased my training load slightly.


So, what's going on?

The fact that I was able to see much more rapid improvement to the insomnia on round 2 while simultaneously maintaining or increasing my training load suggests that overtraining is not the cause.

It's also looking like psychological stress is not the cause.  In April, my insomnia didn't go away once I had run the race I was training for.  It also didn't come back when my big May event approached.  And in June, when it did come back, I was in a fairly low-stress period with no races at all in the near future.

Another thing that stands out to me is that this is now two rounds of insomnia which went away 4 to 6 days after I started taking both phosphatidyl serine and magnesium.  This could be a total coincidence, or it could be a placebo effect, or it could mean that one or both of these were the cause of the improvement.  Without much other information to go on, it has made me move magnesium deficiency or wonky nighttime cortisol (either rising too early in the nighttime or rising too high) into position as the two prime suspects.  Magnesium deficiency in particular makes an interesting candidate since it could also explain why it took my body two months to kill off a relatively minor respiratory infection (magnesium deficiency may amplify decreased immune responses induced by strenuous exercise) this May and June.  


Why it might be magnesium deficiency

When I first considered magnesium deficiency as a possible cause of my insomnia, I wasn't too convinced.  Magnesium deficiency is very common in the US population as a whole, but my diet is full of magnesium-rich foods--I eat a lot of leafy greens, oats, fish, and dark chocolate--and hardly any processed food. I figured that if anyone were going to be deficient in magnesium, it probably wouldn't be me.

I changed my mind on this after doing some reading.  First, there are many reasons why people in general can be deficient despite getting a sufficient amount of dietary magnesium.  The interaction with other minerals, such as calcium, can decrease absorption.  Gut inflammation or other gut problems can also decrease absorption.  You, or specifically your kidneys, can also be guilty of magnesium wasting.

Second are several athlete-specific factors.  There is some evidence that prolonged endurance exercise increases the body's magnesium requirement.  This may be due to increased sweat and urinary losses.  In particular, large amounts of magnesium may be lost when exercising in a hot and humid environment.  I live in Atlanta...  Second, athletes participating in sports that require weight control often consume less than even the recommended daily allowance of magnesium, which itself is most likely too low for the general population, not to mention for athletes.  So...prolonged endurance exercise, running in a hot and humid environment, and dieting?  Sounds a bit familiar!

But does magnesium deficiency lead to insomnia?  It's commonly said that it does, although I don't think the actual evidence of a connection between the two is amazingly strong.  However, it is definitely looking possible that one exists.

In one study, magnesium supplementation was associated with statistically significant increases in sleep time and with marginal improvement of early morning awakening.  One possible mechanism for a connection between magnesium and insomnia is that magnesium is an essential cofactor for the activation of tryptophan hydrolase and for the binding of serotonin to its receptor.  In at least one study, in healthy individuals there was a positive correlation between platelet magnesium and serotonin concentrations (this was not the case for patients with depression).  There is also the suggestion that magnesium plays a role in sleep regulation through its function as an agonist of gamma-Aminobutyric acid (GABA), which is involved in sleep.

Unfortunately it's not an easy proposition to simply get tested for magnesium deficiency.  The most common version of the test is a serum magnesium test, but since only about 1% of the body's magnesium stores are found in serum and red blood cells, the magnesium content of these is often not representative of total magnesium status. There is a magnesium retention test, which tracks changes in serum magnesium and excretion following oral loading of magnesium, but one researcher notes that this test is lacking in standardization, plus it appears to me that the results would be affected by anything that causes your kidneys to waste magnesium.

At this point, if I had to place a bet with only the information I have, it would be on magnesium deficiency as the cause of my insomnia.  If I were allowed two guesses as to the cause, they would be magnesium deficiency or wonky cortisol.  I'm not willing to risk losing any more sleep by taking only the magnesium supplement or only the phosphatidyl serine next time this happens, sorry!  If I ever end up with any reason to think that neither of these were the cause and that the real cause was Option C, I'll update this blog.  Though I *really* hope I never have the need to investigate any further...