Five Months to a Functional Foot
A True Story of Anterior Compartment Syndrome
It was the time of year when cold weather and post-holiday burnout drives one to seek indoor activity. My 13 year old son and I needed some fun exercise to shake off the January inertia. We decided to drive to South San Francisco and spend the day jumping on trampolines.
We reached our destination and were presented with a tonnage of paperwork, most of which was liability release jargon presented in a multiplicity of ways. I should have seen this as a “red flag”, but decided to join in anyways. We left the entrance hall and found our way to the arena, observing that the surface was not a large, stretched, canvas but rather a series of squares bordered by corrugated plastic. Though kids bounded and leaped like rabbits, my son and I decided to jump cautiously. We did not want to land on the borders!
Ever the one to take on a challenge, I decide to test my 40 year old body’s limits. I sprang from one square to another, mindful of the hard plastic borders. It felt exhilarating to jump. Everything was great until I landed and dislocated the distal end of my left fibula. The bone literally “popped out”. I had the detached feeling one experiences when an injury occurs. My brain said “uh, that shouldn’t be there”. While in this disembodied state I pushed it back in. After accomplishing this, I collapsed on the trampoline and my ankle swelled to the size of a small balloon.
Endorphins are a powerful ally when something like this happens. I narrated the incident to a paramedic while being ushered to the local Emergency Room, pain scale number rising yet full of animated “shock energy”. The paramedic listened warily, eyeing me closely. His response was “how about some morphine”? I was silenced with a wine glass serving of the drug.
Once there, the Emergency Room staff administered care for a sprain. They used the R.I.C.E. protocol (rest, ice, compression, and elevation), splinted it, and had X-rays taken. There were no breaks or fractures. I seriously sprained many ligaments around the lateral ankle.
After being there for several hours, my son and I were free to leave. I exited on crutches, no painkillers, and an hour and a half drive back home. Since I was the only one able to drive, my foot was not elevated during this time. I would come to know how critical this aspect of healing is.
Pain Sets In
Pain medication started to wear off once I was home. The sensation of pins and needles sticking into my lower left leg and foot was excruciating…at times feeling like my foot was on fire. I started pacing the living room like a caged animal, tears streaming down my face. I couldn’t see how bad the swelling was because my foot was wrapped. Though I tried lying down, several times, my mind would not let me relax from the pain.I called my son’s father in a state of panic. I knew something more serious than the sprain was happening. I had learned of Anterior Compartment Syndrome from training in Hendrickson Method® Manual Therapy. The American Academy of Orthopedic Surgeons describes anterior compartment syndrome as: Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result.In looking at the lateral side of my lower left leg, the skin looked taut and shiny. I knew I had to get to the local Emergency Room fast.
Night and Day in the Emergency Room
We were escorted to the ER upon arrival. I was told to lie down upon the bed and elevate my leg with three pillows. I did this while the nurse administered pain medication and ice, though it just seemed to aggravate things. I knew, from Hendrickson Method® Manual Therapy training, that the left peroneal nerve was irritated from the swelling. This nerve branches out on top of the foot, and so my foot was zinging and prickly. It felt better to dangle my leg off the side of the bed. By early the next morning, the treating physician and nurses brought in two orthopedists, Drs. Harf and Northfield, to examine it.
Dr. Northfield poked my swollen foot with his finger. I felt like I would kill him! Burning nerve pain radiated across the top. He said he was going to use a special gauge to determine the level of pressure in the tissues in my foot and lower leg. The number would help him know if surgery was necessary. He said I could lose my foot if they didn’t operate that morning.
He said it was clear they needed to perform a fasciotomy on my foot, a procedure which relieves pressure and reduces the dangerously high swelling. An online dictionary defines this procedure as “A fasciotomy is performed on other parts of the body to relieve pressure from compression injury to a limb. This type of injury often occurs during contact sports. The blood vessels of the limb are damaged. They swell and leak, causing inflammation. Fluid builds up in the area contained by the fascia. A fasciotomy is done to relieve this pressure and prevent tissue death. Fasciotomy in the limbs is usually done by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure. Then the incision is closed.” http://medicaldictionary.thefreedictionary.com/fasciotomy
He and Dr. Harf would make two incisions on the top of my foot and leave them open.
At that point I was willing to try anything.
Operation
I was prepped for surgery and wheeled into the room. An anesthesiologist numbed me from the waist down, so I was conscious during the procedure. A large blue sheet was used to barricade my view of what was being done. Though I jokingly told Drs. Harf and Northfield I was cool with watching, they strongly said “no”. I guess this wasn’t the time and place to show my anatomy geekiness?
It seemed like buckets of orange fluid were poured over my foot. (I knew it was orange after the procedure since my view was obstructed). Doctor Harf let me know he was making two 1-1/2” inch incisions on top of my foot. The cuts were done below the metatarsal heads of the second and fourth toes, thus avoiding the superficial peroneal nerve. He said they would be a few inches deep, and that I would feel relief from pressure.
He was right. As soon as the incisions were made I felt better. The sensation was like letting air out of a tire! The process took about 5 minutes, and the doctors were happy with their outcome. They “high-fived” with gloves on and grinned at me, letting me know it was a “fine job”.
The wounds were left open on my foot, allowing the fluid to disperse and circulation to improve. I was bandaged up and brought to a room where I was monitored overnight.
Home
I was discharged from the hospital a day later. My loving mother and sister decided to stay a week with me, helping me orient my daily life on crutches. My son’s father also gave support during this time.
My little one bedroom home was transformed into a female camping ground. Everyone had their own “diet”, makeup process each morning, and way they took coffee. Even though I was a bit groggy from Norco painkiller I couldn’t help but laugh!
The presence of my family made the process of purchasing bandages, acclimating to “crutch life”, and doctor’s appointments bearable. Their support helped me live with the discomfort, and made me realize how healing love is.
While they were here, I learned that moving about on crutches really slows a person down. In fact, performing basic tasks like washing one’s hair is pretty dang difficult. I figured out that if I knelt my healing leg on a stool, (wrapped in plastic), twisted my body just so, and leaned under the faucet in my bathtub I could accomplish this task. Believe me, this is not something you try unless you are fairly confident you can bend down pretty far!
I also figured out that it’s easier to carry a small handled bag and “crutch about” when shopping.
Overall, the first week I spent time elevating my foot, changing dressings, applying antibiotic ointment, and icing. Every night I elevated my foot on three stacked pillows. I slept wrapped like a burrito in blankets, face up, with Norco to deaden the pain.
Frankenstein Foot
Two weeks after surgery, my left foot looked like piranha attacked it. Though it looked like “Frankenstein Foot”, I actually did Pilates mat work, upper body weights, and bicycled at the gym daily to keep the endorphins high. This protocol kept me off Norco and only taking 2 NSAIDS a day. Dark chocolate helped too…
The red scabs you see in the photo were from blood blisters as a result of the trauma. They surrounded my foot, so I covered them in Band Aids. The yellow stuff you see within the incisions is called “fibrin”. It was at this stage that I began seeing a plastic surgeon to monitor the wounds healing. He, and my podiatrist, wanted to see if I would need skin grafts.
Thankfully this was not the case!
I had to change the dressings once a day. Prior to wrapping the foot in Ace bandages, I had to apply topical antibiotic ointment and gauze. Once this was done, I placed my lower leg in a half cast to keep my ankle in dorsiflexion.
I saw the plastic surgeon, Dr. Mancusi, once a week through February. Each visit he’d examine them to see if stitches should go in. He decided they should close on their own.
I spent a lot of time reviewing anatomy of the foot while letting the wounds close. In fact, it was Dr. Tom Hendrickson’s book, Massage and Manual Therapy for Orthopedic Conditions, LWW 2009, that helped me understand the healing time.
Manual Therapy
I started treatment with Giles Gamble, Manual Therapist and Senior Instructor in Hendrickson Method®, the second week in February. The wounds were still open and my foot was swollen.
He recognized immediately that my foot and lower leg needed light massage to disperse fluid, and MET (muscle energy technique) to loosen tight muscles, recruit weak ones, and pump the blood and lymph. Many muscles in my foot did not work well because of immobilization. My calf and ankle muscles were really tight from not bending the foot to walk.
He let me know that scar tissue from the fasciaotomy was inhibiting the top of my foot, and the ligaments on the lateral ankle were still healing. The sensation to his touch was “gummy and thick”.
I was shocked at the results of the session.
I could actually press my heel to the floor. Not only that, but my foot and lower leg felt more connected and movable. Though a bit wobbly, I could walk around his treatment room. I wasn’t even wearing a boot yet.
I made sure to reschedule for early March.
Seven Weeks in
By the second week in March I was back at work. I had a black boot that I wore, but the half cast was gone. After two sessions with Giles Gamble, I was able to get around with an Ugg boot on most of the time.
If I was in an area with lots of people, like Whole Food Market, I made sure the supported boot was worn.
I did the stretches that Giles, and my podiatrist, recommended. This involved deep stretching to the calf and ankle. I also did gentle back and forth movements to the ankle, and continued to ice.
As a massage and manual therapist, I had to structure my work day differently. I would work on two or three clients, than elevate my foot for fifteen minutes. I worked this way through March.
Clients were generous and kind with me. Several visited to chat and offered to help out with laundry. I realized how fortunate I am to have such wonderful people around me.
Confidence
Giles taught me that healing from this kind of injury comes in waves. You get better, then plateau for a bit, then get better again. By early May I was walking about without a boot and the wounds were closed.
It was at this stage that he started doing myofascial work on the scars. He also mobilized the calcaneous and the distal end of the fibula.
I finally understood why work on scar tissue can be painful. He literally had to lift the skin off my bones and roll it around to release adhesions. Thankfully, he used contract/relax muscle energy technique to loosen the tissue before manual therapy!
After each session I could walk better. I was able to put a normal shoe on and walk on the treadmill for two miles. It still got swollen, but the ankle felt much stronger.
The Fifth Month
Despite the bruised appearance, and somewhat “tight feeling”, I began running again in June. My podiatrist thought it would take a year, maybe more. The physical therapist felt the same.
Dr. Hendrickson felt I should strengthen my lateral ankle with a resistance band. I made sure to do this every other day, starting around mid-May. I feel that the resistance training, manual therapy, daily exercise, and chiropractic ankle manipulation accelerated my recovery.
My foot is not swelling and I feel great!
I have a deep appreciation and gratitude for the healing hands that helped through this process, giving me confidence and energy to challenge the paradigm of “immobilization”. I felt that I should move my injured foot and ankle, get manual therapy, strengthen it, and use ice for the swelling. Consistent movement allowed me to actively engage in my own rehabilitation, which accelerated the healing time and allows me to participate in the activities I enjoy.
