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Sunday, September 23, 2012

Injuries Afoot


This pretty scene doesn't LOOK dangerous...

The time has come at last to relate the tale of the injury that has had me on crutches for a month now. Part of why the story has been so long in coming is that it took more than three weeks to determine what the injury was. There was no doubt about how it occurred, however. 

The collie and I pose for a post-swim portrait.

It was the first day of my most recent gig looking after Mr. Gorgeous and the weather was exceptionally fine. His owners informed me that their teenage son was routinely convincing Mr. Gorgeous to swim in the lake for exercise and that I was welcome (though not required) to continue this program. Mr. Gorgeous' lakeside house has its own private beach and dock and is a very pleasant place to hang out, especially on a sunny day, so I put on my bikini, strapped Mr. Gorgeous into his lifejacket (in case his aquatic ambition was greater than his stamina), and we made our way down the steep hill to the lake shore.


The rocks that caused all the trouble.

The shallows of Lake Washington, like most lakes and rivers in this area, are lined with stones, most about the size of the palm of your hand, and usually sport a slippery layer of algae. I waded in with Mr. Gorgeous (he was feeling a bit uncertain about the size of the wind-pushed waves), an activity that required quite a bit of sliding and gripping and constantly readjusting my balance as I attempted to walk into the waves on those slick rocks. Mr. Gorgeous ultimately declined to go beyond where his feet could touch, but since I'd already gotten wet and adapted to the chilly water, I decided to go swimming myself. After splashing around a bit and jumping off the dock, lying in the sun to dry off and then sitting in the shade to admire the view a bit longer, Mr. Gorgeous and I made our way back up the steep hill to his house, where I proceeded to read outside on the chaise lounge for about an hour, and at last went in for a long, lovely shower. I had just come back downstairs, clean and happy and ready for dinner, when I put weight on my left foot and experienced a horribly sharp stabbing sensation in my foot near the ankle. My pain scale runs pretty high--scratching my eyeball and having a migraine so severe I thought I might die top the list--but this pain merited a full 9 out of 10. It made me exclaim and jump involuntarily even if I knew I was going to happen. I found I could hobble on the outside of my foot without causing that stabbing pain, but something was clearly wrong. However, the foot wasn't swollen or discolored and had full range of motion when I didn't have weight on it, so I figured it wasn't fractured. I took some Advil, followed the tenants of RICE (rest, ice, compression, elevation), and decided to see what the morning would bring. When I experimentally put weight on it the next morning, the severe stabbing pain was still present. So I called in the cavalry and the cavalry brought crutches. It was eighteen days before I put full weight on my left foot again.


I've actually had quite a bit of trouble with my feet and legs over the years, but never had an injury that required crutches. I was born with short muscles in my legs, to the point that I was a tiptoe walker until I was about six. When I was eight, I developed inflamed growth plates in my feet. This happens when the bones of the leg grow faster than the muscles, causing the tight Achilles tendon to put tremendous strain on the not-yet-calcified growth plate in the heel. Because of my tight calves and hamstrings, I was already predisposed to this condition and then it didn't help that I grew like a weed: I shot up 10 inches in less than three years. Until I stopped growing and my growth plates hardened in my early teens, walking on hard surfaces, walking moderate distances, or running more than a few yards (the condition became apparent when I joined the school's girls basketball team as a third grader) caused pain severe enough that I was forced to limp or walk on tiptoe. Something as simple as a trip to the mall--requiring lots of walking and standing on hard floors--could become an achy, agonizing experience.

The big toe on my left foot is turned out about 31° and is starting to underlap my second toe.

It was while seeing a foot specialist as an eight year-old that I discovered I had another anatomical anomaly: a bunion. A bunion occurs when the big toe starts angling toward toward the second toe, causing first joint to protrude outward. The bunion can get swollen and painful. My bunion is genetic in origin and has gotten more severe and painful over time, though it's better now than when I was working ten hour days on my feet! I've largely found it to be an amusing abnormality, almost like a party trick, though it does make it difficult to find shoes, especially high heels, that will accommodate the bunion's bulge. The way it is deforming my foot also contributes to the fact that in terms of length, my left foot is a full size smaller than my right!

My knees do not line up over my feet. The left foot turns out at approximately 42° and the right at 28°

Another structural anomaly that has present since I was little is that if my knees are pointing forward, my feet turn out. It's more pronounced on the left side than the right. It makes me ill-suited for activities like riding a bicycle that require the feet to point forward because my knees are then forced to turn in. When I pedal a bicycle, my knees cross over the centerline of my body! Between the way my feet and knees turn and my short leg muscles, I've got a bit of a funny gait, most pronounced, again, on the left--I sort of swing my leg around instead of picking the foot up and putting it down in a straight line. It means I'm not cut out for running and I simply physically cannot properly execute the "frog kick" component when swimming breaststroke! None of these imperfections have been disabling (though they have often been painful and placed limitations on my physical activities and my shoe choices over the years), but over time I've come to regard my legs and feet, especially the left side, as inferior products, only adequate as a means of getting around.


And then there was the SI issue. I tentatively took up snowboarding when I was in my teens and one time, when I was fifteen, I took a hard fall on my tailbone on the infamous "Cascade concrete," a surface more akin to ice than snow. I remember sitting there, slightly shocked, making an assessment of my body, and thinking, "Wow, I think I just really hurt myself." But all the parts worked when I tried them and so I got up and continued to snowboard poorly. (Snowboarding poorly is still a great deal of fun, for the record.) My initial assessment had been correct, however. One, I'm pretty sure in retrospect that I fractured my tailbone. For a couple of months, it was too painful for me to sit on directly, but I was too embarrassed by the injury's location to see a doctor. Two, the jarring of the fall put my sacroiliac joint out. It spent fourteen years locked in a twisted position that, unbeknownst to me, was the source of my constant low back and hip pain. I had so many other unpleasant things going on in my life during those fourteen years that the pain in my hips was never a priority. Another reason I didn't attend to it was that I was quite used to having pain in my lower body by that time and I figured it was another manifestation of my oddly angled feet and unusually tight muscles. By the time my physical therapist diagnosed the problem, the SI position was extreme enough that my left leg was more than an inch shorter than my right! Walking around on legs of different lengths is really hard on the body, especially the back. The SI problem is was also responsible, I just learned, for the fact that my left leg is much skinnier than my right. I first noticed this phenomenon when skinny jeans became fashionable. Pants that were tight on my right thigh were loose on the left, so much so that I was compelled to measure the difference: my right thigh had a circumference one inch greater than that of my left. I've lost muscle mass in my right leg since the migraines have forced me to adapt a sedentary lifestyle, but my right calf muscle, for example, is ¾ of an inch larger in circumference than my left. This left-side weakness is the result of long-term irritation of the sciatic nerve.

What does all this medical history have to do with my recent foot injury? We'll get to that soon!

So there I was, dog-sitting and on crutches. I remember, as a kid, thinking that they looked like fun, and maybe crutches are fun if you're young and spry and full of boundless, squirrelly energy, but I found them to be incredibly hard work. Had I not been building up my arm strength through working with horses, I might not have been strong enough to have used crutches at all. The first few days were especially painful, both under the arms and in the palms of my hand, which is where you are suddenly bearing your body weight. It took some time to figure out the rhythm and I failed to negotiate a step my first day and fell hard, resulting in large, ugly bruises on my knees. (After that I carefully made my way up and down stairs by stepping on the outside of my foot.) Another major inconvenience of crutches is that you can't carry anything! That meant I had to hobble around on my foot in order to fill bowls of dog food or glasses of water until I realized that, thanks to the hardwood floors, I could maneuver around the main level of Mr. Gorgeous' house in a wheeled desk chair. Still, it was hard work to get anything done and I couldn't wait to see my PT so she could assess the foot and start treatment.

One of the bruises I sustained while learning to use crutches!

Unfortunately, while I was en route to my PT appointment, my physical therapist tripped and fell, breaking her collarbone. She waited long enough for me to arrive so she could give me the bad news and then she was off to the ER. She's been out of commission this whole time, so I went to see a different physical therapist. He discovered a new symptom that I hadn't been aware of: my injured foot was shockingly cold. He said that I needed to get it X-rayed to make sure there wasn't more extensive damage, such as a small fracture, than I had suspected. So off I went to my primary care doctor's office. The nurse practitioner was also startled and concerned by how cold my foot was. I had pulses in my foot, so it meant that I was still getting blood flow, but it was a worrisome symptom. X-rays revealed nothing more than a bone spur in the area of the foot that hurt when I put weight on it, but my doctor and my nurse practitioner decided someone with more expertise should take a look at it.

As you can see in this X-ray of my foot, there is a substantial space between the cuneiform bone (the blocky bones that connect to the long metatarsals that go out to the toes) connected to my big toe and the 2nd and 3rd cuneiforms. This because my foot is deformed by my bunion, but the podiatrist thought it might represent a dislocation.

Unfortunately, the podiatrist they sent me to was a quack. He was utterly unqualified to diagnose the injury, though he certainly tried. It would have been better off if he'd simply said that he didn't know what the problem was. He took more X-rays and announced that while perhaps there was a dislocation, it was hard to know because it might just be the way the bones of my foot are aligned because of my bunion and the only way to know for sure would be to compare it to a healthy X-ray of my foot. His recommendation was for me to wear a boot 24/7 and not put any weight on it for the next four weeks and that it should fix itself. For good measure, he would also inject the nerve in my leg with lidocaine, creating temporary paralysis of the foot. My mother was not about to let him inject a nerve (a procedure not without risk) without a full explanation of why there might be a nerve problem in my foot, so we consented to the boot and hustled out of there. In one respect he was right: the foot did warm up when it was immobilized by the boot and I think it was ultimately good for it to be stabilized. But the boot was really hard work. It only weighs a little more than two and a half pounds, but hauling that extra weight around on the end of my leg while on crutches and unable to put any of my weight on it was exhausting. By the time I stopped wearing the boot, I'd been exercising so much just getting myself from place to place that I had lost three pounds!

My heavy boot included air bladders at the back of the heel that I inflated with the clever little blue pump to create a snug fit.

My mother had been leery of sending me to a podiatrist in the first place, but we had trusted my doctor's recommendation. For the next assessment, we decided to go to the experts: the foot and ankle clinic run jointly by the university hospital and the excellent regional trauma hospital, but it was a week before they could see me. I spent several stressful days calling various orthopedists to see if anyone could see me sooner and worrying about the undiagnosed state of my injury, especially if it were indeed a dislocation. Dislocated bones in the foot can present only subtly on X-rays, may only hurt while weight-bearing, and cause coldness in the foot: in other words, I had all the symptoms. The podiatrist's claim that a month in the boot would cause things to straighten out on their own was just plain wrong: dislocated bones need to be put back in place and dislocations in the mid-foot, where I was having my pain, often require surgery to correct. I wanted a definitive diagnosis very badly! My weekend trip to the San Juan Islands helped me relax some and we had set things up in the house to make it easier for me to move around with my boot on, but I was so happy when the day of my appointment at the specialty clinic finally came.

That extra pointed tip on my navicular bone was deemed responsible for my foot pain. 

After a very thorough exam and more X-rays, the diagnosis came back as this: I actually was suffering from two injuries. The pain in my foot was caused by the bone spur and the coldness was being caused by pressure on a nerve because of a back injury. Slipping around and using my feet to stabilize myself on the rocks had caused hyper-extension of my foot and sent the bone spur poking places that it shouldn't and apparently in my efforts to stay balanced, I'd hurt my back, too. I hadn't felt any back pain, but after I started standing on my foot and walking just a little bit, there it was: in my lower back, on the lefthand side, right next to the spine. Because I'd been on crutches since the morning after the injury, I'd never realized it was there. The specialist prescribed physical therapy to address the back issue, which would relieve pressure on the nerve and should alleviate the coldness, the flatness of my arch (it had collapsed), and the occasional burning sensation in the foot. He advised me to stop wearing the boot, since it would likely start causing strain-related problems that would outweigh the benefits, and to carefully begin standing and walking on the foot as much as pain would allow as inflammation around the bone spur died down.

 The muscles supporting my spine are not doing a good job of stabilizing my vertebrae!

To say that I was hugely relieved not to have a serious injury that would require surgery was an understatement! I started PT again where we are working on strengthening the tiny muscles--the multifidi--that should be supporting the spine. Mine aren't, so my vertebrae are moving from side to side much more than they should, which irritates the nerves. The goal is also to eventually help me building up the strength and flexibility in my left leg, though it's possible down the road, if things don't improve, I might need to consult a neurologist. I've been standing on the foot and walking just a few steps here and there--like from my bed to the closet and other short distances--but have found that while I no longer have the terrible stabbing sensation, I can't move flex my ankle very much if I have weight on it. That means I still have to get around on crutches most of the time. If the problem continues, it's possible that it will be necessary to remove the bone spur or take some other more intensive action. In the meantime, because my arch has flattened, I have been wearing my Dansko shoes to help me stand properly. Otherwise, it puts a lot of foreign strain on my muscles. A month is a long time to be on crutches and it looks like I'll still have to rely on them for several more weeks, but it certainly is easier to get around if I don't have that heavy boot on and I can stand when I need to! I'm also extremely glad I won't have to wear the boot on my upcoming trip to Florida for a wedding because I have the cutest outfit and the bulky boot would have totally ruined the effect! I've had to cancel my lessons with Drifter indefinitely and have been unable to swim and have been severely limited in my ability to take photos, but what can you do? Swimming in the lake with Mr. Gorgeous was a perfectly reasonable undertaking. I've slipped around on lake- and river-bottom rocks many times without sustaining injury. It's an unfortunate twist in my ongoing disability saga and simply getting around the house sucks up a lot of my energy, but it's just what I have to live with.

When walking, because of the way
my hips, knees & feet are aligned,
my leg crosses in front of my body
So what does this foot injury have to do with my long history of issues with the bones, muscles, and nerves in my feet and legs? Well, quite a bit. I was born with short hamstrings, which I've learned can also be connected to an innate instability of the spine, which in turn can impact muscle strength and development. Whether I was born with inward turning knees or my muscle imbalances prevented my knees from assuming a normal, forward-facing position as I grew, I developed a funny gait, especially on my left side, to compensate for the tight muscles and abnormal leg position. An uneven gait can cause further back problems and I'm wondering now if life-long spinal instability and my leg issues may be the reason why I've always had poor balance. My poor balance made it very hard to snowboard, thus upping the chances of me taking a hard fall on my tailbone like I did when I was fifteen. Fifty-eight percent of sacroiliac joint injuries like mine stem from similar traumatic accidents, but my long-standing weakness and instability and stress on the muscles, joints, and nerves, especially on the left-hand side, made me predisposed to get such an injury. And it was the left-hand sacroiliac joint that suffered the damage and spent fourteen years in a rotated position. As I've said, that made one leg much shorter than the other, further impacting my gait, further destabilizing my spine, and in addition to putting pressure on my left-hand sciatic nerve, leading to increased stiffness and muscle atrophy, I'm wondering now if the back pain I used to also have higher in my back created pressure on the spinal cord and is why I have the world's flattest posterior. Obviously, from a genetic standpoint, it's not a place where my body stores much fat, but it intrigues me to think that pressure on the nerves might have contributed to the lack of development in my gluts over the years. It might also explain why in years past I put relatively little muscle on my legs for the amount of exercise--including weight-lifting--I was engaged in. And then it happens that when I do finally get my SI straightened out a couple of years ago, it comes at a time when I'm forced by the migraines to keep my physical activity to a minimum. That means even if my left leg is getting better information through the nerve and had more capacity to put on muscle, it didn't get the opportunity. And meanwhile the weakness of the little muscles stabilizing my spine remained unaddressed. That means I waded into the water with Mr. Gorgeous with a balance problem, a structurally weak foot that could easily move in ways that it shouldn't (thereby allowing the previously unproblematic bone spur to poke into places where it didn't belong), and a spine unable to keep its vertebrae in line (making it very easy for one to get tweaked in a way that put pressure on the nerves). I was set up for exactly this kind of injury to happen.

My legs as seen from behind
and reflected in a mirror--my left
leg is therefore the one on the right.
The size difference is very clear!
On the bright side, I'm glad to finally have some more insight into my long history of stiffness, pain, and injuries. Looking back at old photos, I'm rather amazed to see that the differences in the musculature of my legs was already visible by the time I was four. That means I've been getting poor nerve information in my left leg since I was a little kid! No wonder I've always had wimpy legs, skimpy gluts, back aches, and had trouble with roller skates, snowboards, and bicycles! It's a bit of a relief, really, to realize that innate structural issues causing irritation of the nerves are responsible for some of my physical ineptitude and not a lack of, say, effort or desire or moral fiber. This inconvenient injury means that I'll finally be able to address this left-side weakness that has been hampering my body since I was a toddler, which should ultimately result in stronger, more flexible, and more EVEN legs. I might get a better ability to balance out of the deal, too. Come next summer, if I dare to go wading in the lake (I may not!), it is possible that my body will have the proper tools to slip, slide, and then stand again unharmed.

*****
The injury update, two months out:

A week and a half after starting spine stabilizing exercises, I was able to start walking again without crutches. As communication between my nerves and my foot improved, the bones in my foot went back into their proper positions and the bone spur ceased to poke into where it didn't belong. My strength and flexibility has improved tremendously, my arch has almost completely reformed, and as of the last week or so, there is no longer any coldness in the foot at all. My sciatic pain has lessened considerably in the last few weeks as well. I still have the occasional issue if I walk on uneven ground, but the change from where I was a month ago to where I am now is almost miraculous! It underscores the importance of getting a good diagnosis and the right treatment. I'm glad I persisted in getting a second opinion and that in the end, some very simple muscle strengthening exercises were all the cure I needed!

3 comments:

  1. This is very important subject dealing with our body. Challenging yet very nice informative issues. Thanks for taking the time to discuss that. Keep it up!

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  2. The path to recovery tends to be harrowing at times. After all, it is not a swift and smooth one: there are rough parts, and a bunch of stumbles along the way. It is always about wading through them carefully and wisely, with all the assistance and professional medical advice and support we can get.

    Pearlie Kreidler @ US Healthworks

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  3. i have the same problem.... can you help me

    ReplyDelete