Instructions . . .

Last night it occurred to me that I had thought through some aspects of the recovery period . . . Thanksgiving break would be perfect for a teacher to have foot surgery, right? And just a few weeks beyond that break would be another 2-week break, providing more rest for my foot.  Perfect! But then I was reading yet another article on the Internet about bunion surgery, and I ran across this little part of post-op instructions from one woman's doc: "No driving for 6 weeks." Ruh roh! THAT is just not going to work. I can't imagine trying to do my life for 6 weeks without driving.  Actually, even one day would be tricky. Mom's taxi, and all that. Maybe I can get good enough driving with my left foot? Sounds risky.  So I bugged Dr. L's office again today for the post-op instructions I meant to ask for yesterday. They FAXed them to me, but those were only for the first 24 hours. Not enough to help me plan for weeks of recovery.  I called back, and she said if she didn't have something on file already, she would have Dr. L write them out and FAX them to me.  I was impressed to see that within the hour they sent me a full page of written instructions from the doc. After about 10 mins of deciphering his true-to-form physician's handwriting, here's what I read:
Julie [I like it! The personal touch!]
1) Rest, ice, and elevation x 72 hours.
2) Stand and walk to tolerance.
3) You can drive when discomfort subsides and you can push brake without pain.
4) Removal of sutures in 2 weeks
5) Physical Therapy starts at 1 month post-op.  2-4 sessions depending on patient.
6) Pain meds: you will use every 4-6 hours for first 3-5 days, depending on which procedure is done.
If you get joint replaced, you should be back to conventional shoes in 4-6 weeks.  If you get structural correction with metatarsal fracture, you should be back to conventional shoes in 8-12 weeks.


Regarding the "which surgery" part, Dr. L says there is a possibility he will go in and find that the joint is further deteriorated than the MRI showed, in which case he'll replace the joint, rather than breaking and fixing it.

So, I'm still not sure I know how long I have to wait to drive, but maybe I can fudge by using the heel of that foot? Good thing Jono has his learner's permit!

Good day, good day, bad day, good day, good day

Two adjustments in the last two weeks seem to be changing the severity of my foot pain: I stopped running, and I changed the orthotics I'm wearing.  After Dr. L confirmed my suspicion that the expensive orthotics I bought two years ago were doing me no good, I switched back to a $20 pair that my physical therapist had suggested I buy from Bed, Bath, & Beyond.  They are firmer and provide better arch support.  Sooooo frustrating that wearing the cheaper ones would have been better for my foot all along!  
So lately, the foot pain has subsided significantly. I've taken to characterizing each day as "good foot day" or "bad foot day." This has me wondering if I should even pursue surgery.  Such a huge decision! 
I went back to Dr. L today to find out the results of my MRI.  The gist is that the fractured sesamoid seems to be an old injury, and the main concern is the cartilage loss and beginning of arthritis in my great toe on the right foot. When I told him about the pain subsiding somewhat, he said a few things: 1) It's my foot, and I decide what to live with and how to proceed, 2) It won't get any better, only worse over time, 3) I could be facing a much worse surgery situation a few years down the road because of continuing cartilage loss.
So here's what I decided for today: 

• I went ahead and made 2 appointments, one for casting for a new pair of orthotics next week, and the other for the Tuesday before Thanksgiving, for surgery. That way, I have my preferred date on his schedule, and, as Dr. L said, I can always cancel it if I decide against surgery.  
• I'm going to keep reading an eBook I ordered called The Bunion Survivor's guide to Successful Surgery and Recovery.  
• I'm going to do more investigating into whether Dr. L is the right surgeon for me. 
• And I'm going to keep monitoring my foot's pain level and listening to my inner voice about whether going forward with surgery is the right decision (good advice from a wise friend--thanks, Debi!).  

Here is the official MRI report:


Findings:
There is normal marrow signal maintained within the metatarsals, specifically the head of the second metatarsal displays normal signal intensity.
There is moderate cartilage loss and narrowing involving the first metatarsal phalangeal joint.  There is some minimal bony overgrowth involving the first metatarsal head, as well as the base of the first proximal phalanx.  There is associate joint space narrowing and mild bony overgrowth.  There is perhaps some very minimal subcortical edema involving the articular margin of the first metatarsal head, as well as the base of the proximal first phalanx.  This is however, very subtle.  
There appears to be focal small area of edema involving the tibial sesamoid.  No displaced fracture is evident. There is minimal amount of surrounding fluid at this site.  The contiguous flexor tendon appears intact and normal in signal intensity. 
The intrinsic musculature of the right midfoot displays normal signal intensity.  The dorsal, as well as the planar tendons appear intact and normal in signal intensity.
The distal metatarsals appear intact and normal in signal intensity. The joint spaces appear maintained. 


IMPRESSION:
1. There is a focal area moderate marrow edema involving the tibial sesamoid. This is reportedly at the site of patient's area of pain/trauma. As this edema is nonspecific, could represent bony contusion. However, an underlying subtle occult fracture could also be present. This could be further characterized with thin-section CT for improved bony detail. No definite displaced fracture is evident.
2. There is moderate cartilage loss and narrowing involving the first metatarsal phalangeal joint with minimal subchondral edema and bony overgrowth.
3. The second metatarsal head is normal in signal intensity, as are the remaining metatarsals. 

Fascinating! And bad news . . .

I've had to baby my feet since my early 20's.  At age 16, I watched my mom go through painful bunion surgery.  Looking at my own two feet, I could tell I had inherited her problematic foot structure.  I pretty much assumed that her painful bunions were my future.  Looking back, I wish I'd known that I could be more proactive in keeping my large toe joints from drifting and creating those painful bunions.  Good orthotics for the last 20 years probably would have gone a long way.  But, that's water under the bridge.  For the last 20 years, all I've done for my feet is try to wear sensible shoes instead of pointy-toed heels.  My shoe choices have been driven by comfort rather than fashion.

All that changed when Hurricane Ike roared through Houston in September 2008.  When I saw the storm coming, I loaded up 2 of my 3 kids and hit the road, traveling to St. Louis, where I grew up and my mom and 3 of my sisters still lived.  The drive was long (13 hours), but the trip was worth it!  My oldest daughter was in her junior year at Washington University in St. Louis, so we got to visit her and hang out with family for 9 days--Hurrication!--until our schools could reopen.  One night as I left my sister's house in the dark, I thought I had stepped down the last of her cement steps, but there was one more.  I twisted my left ankle, terribly injuring tendons on both sides of the foot.  Swelling, bruising, and lots of pain eventually led to an MRI, which revealed I have an extra bone in my foot, an accessory navicular bone, which can cause the types of foot structure problems I suffer from.  My physical therapist suggested I get orthotics.  So I visited a podiatrist and paid out-of-pocket for a pair of custom orthotics (insurance company denied this important preventive health care expense, of course!).  After about a year and lots of anti-inflammatories and physical therapy, the pain in that foot simmered down to manageable.

Fast-forward to the present, September 2010.  I got very excited in the past few weeks about a running program called "Couch to 5K."  I finally found something that would keep me motivated to get out there and exercise, and I was excited about the goal of running the 5K in the Susan Komen Race for the Cure.  But then my right foot got dramatically worse.  It began hurting all day long, and I was icing it a few times a day just to get through.  I finally had to face the music and say, "Julie, you've got to stop this running program!  You can't be a runner if you have bad feet."  But my foot had been hurting more than usual all summer, well before I started running, so there's something else going on, too. I've been trying to buy shoes all summer, but can't because my foot hurts too badly.  I see a comfortable-looking shoe on the rack, put it on, and yelp in pain, slipping it off as carefully as I can.  Everything presses on that big toe joint; everything hurts. Then my foot started waking me up at night, screaming in pain.  I decided I'd better figure out what's going on.  I saw 2 podiatrists this week.  The first one I saw  just pushed surgery, without even showing me my x-rays and explaining why.  He was full of ego.  Really turned me off.  But on Wednesday of last week, the second doctor spent an hour with me, going slowly through my x-rays, and explaining everything he saw.  It fascinates me to look at x-rays and see what's going on inside--I should have gone into medicine, apparently.  Listening to him show me what he saw on the x-ray, it makes sense that my foot is hurting so badly!

First, there is a small bone in my right foot that is broken into 3 pieces. You can see it if you compare the left foot to the right foot.  There are two small, round bones under the base of the big toe bone, called the sesamoids.  You can see them through the toe bone on a normal x-ray.  On an x-ray of a foot that has a bunion, the large toe bone is displaced, so one of the sesamoids seems to be on the side of the big toe bone, because the bone has drifted off-center for years.  So if you look at those 2 little bones on my right foot x-ray, you can see that the one that's still under the toe bone is broken into 3 pieces.  BUT, he's not even sure that's what's causing the pain.  It might be an old break that never healed.  More concerning is what's visible in the spaces between the metatarsals and phalanges.  On my 2nd through 5th toes, the spaces are good-sized and well-defined.  It's not really space, of course; that's where cartilage is.  But on the large toes, the spaces are fuzzy and smaller.  And the large toe bone has white areas just beyond the space.  This means the cartilage is worn away and the bone is developing arthritis.  Groan.  I suspected as much.  

The last interesting thing on the x-ray is that you can see the extra bone I have in each foot, the accessory navicular.  It's rare (2-12% of the population), and it's the primary cause of all my foot mechanics and eventual bone structure problems.

Here's a frustrating little tidbit I learned at my appointments: both doctors said the orthotics I paid so much money for 2 years ago are not helping my feet.  They are too flexible and don't have a high enough arch. Apparently, some docs prescribe this type because they are easy to get used to, so they don't have to listen to patients complain about their orthotics killing them during the break-in period.  Ugh.  Frustrating. 

So, I had hoped, when all this pain started up and I sought the help of podiatrists, to find a way to get my foot back to functionality and pain-free without surgery.  But now I'm not sure that's going to be possible.  Apparently, with cartilage loss already beginning, it's all downhill from here.  But Dr. L. wants to get an MRI first, to see what's really going on with the cartilage and with that cracked up sesamoid. It will tell him what he has to do when he gets in there, just fix the bunion, or replace the entire joint.  Dr. L. suggests Thanksgiving for surgery.  So this blog is my attempt to document my journey forward.  I think the decision to let someone cut on my foot and mess around with the bones is a huge one.  I've heard so many horror stories about bunionectomies gone wrong, including my own mother's.   I'm on my feet all the time as a teacher.  I don't want to make any unwise moves that will result in lifelong foot pain or deformity.  On the other hand, that's basically what I've got right now, so I'm open to the possibility of surgical intervention, and I'm cautiously moving forward.  MRI results on Tuesday . . . we'll see what he says.