Saturday, December 7, 2019

Haglund's deformity removal surgery (calcaneal osteotomy and bursectomy)

For several years I've battled insertional Achilles tendinosis and bursitis. Or so I thought. In reality, I've had a misdiagnosed Haglund's deformity. I will spare you the details, except the "tells" of Haglund's deformity in a runner:

1. Pain rapidly subsides after activity, unlike tendinosis which usually aches. If I had heel pain after a run, I might have trouble walking for an hour afterward, but by the next morning it almost felt good as new. Even if I race a 50 miler and incurred immense pain by the end, I felt ready to run in a couple of days.

2. A hard lump in the heel that does not go away with icing. Bursitis and general inflammation should go away with a week of rest and ice foot baths. Mine did not.

3. Tightness that does not improve with stretching and targeted bodyweight exercises. Insertional tendinosis should respond to eccentric heel drops, dynamic balance exercises with kettle bells, and light, dynamic stretching. Mine did not.

I finally had enough of the run-around with botched races and constant heel pain, and went to see an orthopedist with some specialization in athletes. I was diagnosed with a Haglund's deformity right away. If you have symptoms matching mine above, I encourage you to seek an opinion from an orthopedist.

What is a Haglund's deformity? In runners, it is probably caused by running through a long bout of Achilles tendinosis, when the calf muscles and Achilles are generally tighter than normal. The tightness puts excess tension on the calcaneous (heel bone), which responds by growing upward and outward, forming a sharp corner in the heel across which the Achilles tendon glides, obviously leading to irritation and pain. It's an obvious solution from the bone's perspective - to relieve tension, grow toward it!

There is no way to fix this condition with conservative treatment. I have run with heel lifts and have removed the heel counters from my shoes, and even that provides minimal improvement, so I eagerly agreed to a surgical approach.

Below, I will document my recovery so you can judge whether you should undergo surgery. As of starting this entry (3 days after surgery), I can say I already do not regret it, but I know it will be a long road to recovery.

Day 0: surgery

I have not eaten since 5:30 am, and my surgery is at 3:00 pm. It's actually not that bad. I spent the day getting the house ready, setting up an air mattress with lots of pillows in the living room. That will be my home for the next 2 weeks while I'm in the surgical splint.

I was taken to the pre-op room where I answered some questions, met with my orthopedist and anesthesiologist, and got my IV set up. The orthopedist is optimistic - I'm relatively young, healthy, and thankfully do not have to have my Achilles tendon detached/bisected, so my recovery should be fast (bone heals faster than the Achilles). Incisions are usually made on the lateral side of the foot, but because most of the deformity is on the medial side, I will have a medial incision. This will require two nerve blocks instead of one. The bursa will also be removed - so no bursitis ever again on the right side, which is a fun bonus.

 In the pre-op room. You can see the bony bulge on the right foot - it's not huge, but this is its fully-rested state with no swelling.

The anesthesiologist gives me a sedative to help me space out as I'm wheeled into the operating room. I'm conscious enough to say "hello" to the nurses and flip myself onto the operating table. The anesthesiologist spends what feels like an eternity setting up the popliteal nerve block - my leg spasms, I feel electric, burning sensations...it's not that fun. The popliteal is required for both lateral and medial incisions, so nobody misses out on the fun. The adductor nerve block is easy and I don't feel a thing. I crack jokes with the anesthesiologist, which I think means the sedative is wearing off. Soon I drift off into general anesthesia...

...and awaken feeling terrible. I'm nauseated and having hot and cold flashes. I can't tell who is doing what around me, but people are trying to get me dressed. They give me some food. Somehow I make it to my car and my wife drives me home. I get queasy, and she passes me a plastic bag. A few minutes later I vomit in the back seat (no big deal, I'm well-trained in vomiting). I get home in a haze, eat a cup of broth, take my oxycodone, and drift off to sleep. I wake up and decide to take the higher dose of oxycodone on the off-chance the nerve block wears off.

Day 1: nerve block wears off, the night of living hell

I'm still in a haze when I wake up and don't have an appetite. I take a Zofran and feel well enough to sip coffee and have a little food. My toes are starting to tingle and I'm beginning to feel some pain in my heel, so the nerve block is starting to wear off after about 16 hours. By noon the pain is setting in, but it's manageable. I try to watch TV but it's hard to focus - I'm still exhausted from the surgery and anesthesia, and the pain keeps working its way into my thoughts. I keep the foot elevated well above my heart, which seems to help the pain a lot.

 The beefy splint, elevated on a few pillows. In the background: Night Court. I am unable to pay attention, which may actually be for the best.

Also, interesting side note - I was sent home without crutches but a very burly splint. I'm only supposed to hobble to the bathroom and to get food. My guess is this keeps the blood flowing and prevents total stiffening of the ankle. I am, amazingly, able to hobble without too much pain.

Toward the end of the evening I can tell the night is going to suck. My heel bone is starting to burn and I can now feel the incision. Up until now, the pain has been dull and diffuse, but when specific features hurt it becomes mentally hard to manage it all. I'm on the maximum dose of oxycodone, so I have no recourse if things get worse.

After sleeping for a couple of hours, I wake up to waves of severe pain deep in my heel. I have to bite the comforter and swing my good leg just to get a grip. I put on some headphones and listen to some heavy music to try to bury the pain, but all I can do is hold on until it's time for another round of pills. Rinse and repeat until the morning.

Day 2: pain redux, dressing redo

The heel and incision pain is fading, but I now feel an incredible tightness above my heel that constricts my Achilles and makes it impossible to hobble. I am now crawling around the house. After waffling back and forth, my wife pushes me to call the orthopedist's office. They tell me it sounds like the dressing is too tight, so we go in to get things adjusted.

 Getting the dressing re-applied so it isn't so tight. I'm amazed at how healthy the incision looks.

The stitching looks healthy! Very little blood and just a bit of fluid. Removing the dressing gives me immediate relief. I was previously wrapped with gauze, surgical wrap, and a stretch bandage - the surgeon decides I can go home with just gauze and a loose bandage, since the wound is healing and I haven't had any work done on the Achilles.

 A closer look - not bad for having the bone sawed down two days ago.

After fussing with the splint I find a setting where I can walk again without pain. While I'm still on the maximum dose of oxycodone, I can tell the bone is settling down.

Day 3: pain subsiding fast

I am now down to the regular dose of oxycodone, and my appetite has fully returned. I can fully focus on tasks - doing a little bit of work, watching some TV, and giving myself a quick bath with a wash cloth. Walking gives a bit of bone pain, but it fades immediately; I can only feel the incision when something presses on it.

Day 5: opiates done, cruising the neighborhood, CBD helps

Totally off oxycodone now, which has lifted my brain fog so that I can get a bit more work done and be there for my family.  I borrowed some crutches from a kind neighbor, and can help my wife walk the dog around the neighborhood. I can put about 30% of my weight on my post-surgery foot on these walks without incurring much pain. The most important tip I have is to keep elevating the foot, keep hydrating and eating to support recovery, and keep moving as much as pain allows. My rule is that the pain should improve day to day - if it doesn't, I pushed it too hard.

Also, once I ceased the hydrocodone, I started to feel some burning pain in the heel bone, especially on the lateral side. Tylenol helps, but doesn't get me over the hump. I've found that supplementing with CBD, as long as I don't consciously focus on the pain, allows me to go about my daily life without noticing anything. To be fair, it might only be a 3/10 on the pain scale, but that gets annoying day in and day out.

Day 7: Boot sucks

Who designed this thing? The rivets for the straps sit right over my ankle bone; even with foam padding the pressure causes my ankle to hurt unless I slide my foot too far forward in the boot. I'm spending time with the boot off and my foot elevated, and it feels amazing. There's also some strange kind of acne/hair follicle irritation developing. Hopefully it doesn't get too crazy before I get this boot off in another week. I do feel like the gauze was wrapped in a way that limits my ability to dorsiflex my foot. Not sure if that is intentional or not, but that also limits my ability to load weight on the foot.

More than the rivets, the boot just doesn't seem to be designed for my foot/leg. I have muscular legs and wide feet, but an ankle as narrow as anyone else, while the boot is shaped for a leg with roughly equal width from toe to knee. Probably fits seniors and the obese, but not me.

Originally, I tackled the oddities of the boot fit with some sheets of plush fleece from a fabric store. However, that padding seemed to take pressure off of one region and put it on another, and it didn't breathe so well so the boot got damp. Instead, I've removed all of the extraneous padding from the boot, especially around the heel, so that the heel, rather than being padded tightly in place, is more or less floating in empty space. Way better solution. Awkward to walk in, but a way better solution.

Day 8: pushed it too hard 

In an effort to get to be early, I rush around the house cleaning up, turning off lights, locking doors, etc., and then hop into bed. Not a minute later, I'm greeted with the nastiest pain I've felt in recent memory (much worse than night 2). Burning, ripping, tearing pain and electrical shocks in my heel. I have to pull a pillow over my face to muffle my screaming. And within a couple of minutes - gone, never to return.

I think I'm learning my limits still, but it's quite hard because I can't tell if I'm overdoing it until it's too late.

Day 11: no pain

Basically none, now. I can put full weight on my heel so I don't need to hobble - I just walk with one foot a couple of inches above the other, so my gait appears something like half-man and half-duck. I am getting occasional nerve tingling in the heel and up my leg, but that's probably from being in a splint for two weeks. I've had to pad my heel because I've created a divot in the foam base.


Day 14: stitches out!

Getting the gauze off felt amazing. As the nerves are reconnecting, the skin around my heel and even on the bottom of my foot is very sensitive - the texture of the gauze wrap was almost painful at times. With that wave of relief I barely noticed the stitches getting removed. I think the wound looks pretty healthy, the only issue right now is some latent bruising around my arch and the lateral side of my foot, almost like the bruising when someone breaks their ankle and fluid settles and swells the heel.

Stitches about to come out... 

 And they're gone! The orange lines are benzoin to make the steri-strips, which will go on to ensure the wound doesn't open over the next few days, stick better to my skin. Spoiler: it didn't really work that well. My feet sweat too much.

Day 17: nerve pains, walking gains

I'm able to go on walks around the neighborhood with real shoes on. My lord, my ankle and Achilles are stiff. I'm not hobbling, but I am walking like an old man with arthritis. The foot is still quite swollen, so I'm going to focus on elevation today - but isn't swelling and inflammation the body's healing response? Do I want to really limit it that much? It's like icing - it feels good, but it also limits healing.

Lots of weird electric shock sensations on the bottom of my heel, and when I push my range of motion I occasionally feel a sharp pain. I'm confident this is just hypersensitive nerves readjusting, especially since my skin is extra taught from the stitching. I do occasionally feel pain where there is bruising, but it's dull and doesn't worry me too much.

Just letting this warlock air out a bit. My ankle bone remains buried under fluid. 

Day 18: a breakthrough

Well, I still have strange nerve sensations, but they are rarer and more diffuse. The skin on my heel is desensitizing and I can feel the incision starting to smooth out.

At the back corner between my property and my neighbor's property is a dense grove of Siberian Elm. These are not native to Colorado, but they thrive in dry, cold winters and harsh summers, so even though they grow somewhat disorganized, they're still valuable for shade and wind breaks. A big one was chopped down maybe 10 years ago, but the root system was left intact - and of course, being the amazing tree it is, it sprouted about 20 smaller trees from the old trunk and from the exposed roots. It's looked a bit of a mess for a while - I'd call it a rat's nest of a tree, with branches down to the ground - but I finally had enough and asked my neighbor if I could hop the fence and trim everything up.

So, I popped into some old running shoes and spent 4 hours trimming away the lower branches, thinning some of the canopy, and clearing out leaves and old blown-out wood fencing and trash. It looks great! And I have little fatigue from all that work, and no pain at the end of the day laying in bed. I actually think the isometric loading helped my heel and ankle loosen up and calmed the nerves down. So if I could suggest anything...once you feel stable enough to do some light activity that doesn't require lots of walking, do it!

Day 34: growing pains, no more scabs

All the scabs have now fallen off and the scar is turning pink - a good sign! The skin was initially very hard and lumpy around the incision, in part from the stitches. I've been massaging cocoa butter firmly into the scar twice a day for 5-10 minutes and it seems to be loosening things up. The skin around the incision is much less sensitive. However, I can feel a lot of...reconstruction happening where there used to be a Haglund's deformity. At this point, I'm guessing the bursa is growing back and the body is reshaping the Achilles tendon. There's some latent swelling along the tendon, but I'm getting more and more flexibility back.

Really, even a week ago this still looked like a war zone.

I believe, however, that I developed some peroneal tendonitis either in the boot or while weaning off the boot. The boot required me to walk with my toes pointed outward (otherwise I would be moving forward like a bike with square wheels...up...down...up...down). Now that I'm walking normally, the peroneal tendons on the lateral side of my foot are quite sore, especially near their insertion and near their guiding ligaments. Some resistant band exercises, heat, and elevation for the occasional swelling are taking the edge off. Since the scabs have fallen off, I am officially good to go on hot/cold water soaks.

Day 42: scar tissue, nerve block remnants

I went for my 6 week followup - it's usually 8 weeks, but they put me on an accelerated schedule because I'm a "young athlete". X-rays show complete healing of the calcaneous to the correct, non-Haglund's shape, and the swelling is essentially gone, so they let me loose with the instructions to ramp up activity - hiking right now, and then adding a few short runs to the hike. Swelling will be my guide.

The peroneal tendon pain is waning, probably from the exercises, but I still have some mild tingling in that area and on the bottom of my heel. Apparently the nerve blocks can have some long lasting effects, but I imagine that continuing to floss the nerves and get the ankle active are only going to help.

Whenever I stand from sitting, my ankle is still stiff, but when I stand from laying down, it's actually not too bad (it's generally best in the morning), so I think some of this could be due to the mobility of the entire leg, not just the ankle. I'm going to start doing eccentric heel drops, glute activation exercises, etc., to try to move things along.

So far, even without having returned to running, the surgery has been worth it. I don't feel that achy Haglund's deformity pain when I walk around or squat to get something off the ground; it's a weight that's been lifted from my soul. It has always been this shadow that reminded me that I wasn't physically well and it crept into everything I did - even work around the house or the yard.

Day 95: nerve dysfunction, tight peroneals, running getting real

I'm running up to 5 miles at a time now, with some brief swelling that pops up at random. It seems triggered by sitting for a long time, or running with a tight ankle (see below).

The good news: I can walk normally with minimal nerve issues, I can run normally after about half a mile of warming up, and I can run in shoes with a hard heel.

The bad news: I still have to floss my sural nerve, and I have discovered it is my peroneal tendon that is super tight. Both are slowly improving with some theraband work. The nerve is really bothersome - I can feel its tightness when I stretch my calf or get up first thing in the morning. It is not the Achilles, because the tightness results in tingling on the bottom and lateral side of my heel, well away from the tendon and the former Haglund's deformity. I put my money on some damage from the nerve block, to be honest, after reading about the complication rate (it was quoted to me as "less than 0.02%", but it turns out that complications lasting up to 12 months aren't counted...). I would suggest you refuse the nerve block; mine wore off pretty fast, it was painful going in, and it seems to be causing me trouble months later.

Day 105: hitchin' post

This (the whole experience, surgery to now) is the hardest running challenge I've ever had to deal with. I don't know if the sudden bout of cold weather did it, or pushed slightly too hard, but the nerve pain stopped getting better and my Achilles is still a bit sore near the insertion point. I've taken 3 days off running and feel much better. I think at least a 5 day break will get this in check.

I've started doing eccentric heel drops, which are really helping.

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