A Good Doctor, But Bad News

That "x" with the arrow is the top portion of the joint that is arthritic. Follow it downward. That whole surface is ruined.

I have lingering exhaustion from yesterday’s blood draw and appointment with the ankle surgeon. After triumphing over those major hurdles, I still worked a full day. I slept horrendously, so it’s no surprise that I’m feeling as depleted as I am this morning. It’s not just the physical energy output that tires me, but the stress and effort required to deal with the blood draw and the heavy news at the surgeon. By midday, I had no interest or ability to talk and I fought back tears of sadness all afternoon, driven to emotionally-volatile position largely by fatigue and being overtaxed, as well as the true meaning of the visit with the surgeon sinking in.

Although the appointment of the surgeon was upsetting because of the news he gave me, I really like him. I found him to have a calming demeanor. He was easy to talk to and understand. He spoke to me clearly, respectfully, patiently, and confidently. I’m glad Ben handled the driving and accompanied me in the room so that he could hear the discussion and pose his own questions too. Ultimately, this will be a big decision.

This orthopedic surgeon specializes in foot and ankle surgery, and he operated on my very athletic brother-in-law who has been quite happy with the state of his post-operative ankle. Although our conditions are totally different, it’s reassuring to have a personal recommendation from someone I trust and whom I know pushes his body and thrives on physical activity. When I was considering foot surgery last year on my other foot, it was important for me to ask that surgeon about his experience operating in runners. The competitive athletic population did not seem to be his niche, as he only had one anecdote to share about a runner in his twenty years of procedures, even when I specifically inquired about his experience with runners. My confidence faltered further when he shared his opinion that “most people shouldn’t run.” That’s not a perspective that jives with me. Although I agree that there are some contraindications to running, it’s a sport that has played a significant and positive role in my life.

The surgeon yesterday specializes in sports medicine, in addition to his focus on the foot and ankle. He treats athletes of all kinds and tailored his conversation with me to my interest in competitive running and the current ramifications of my injury on my engagement in the sport and how the potential treatments would affect my ability to run, as well as function in daily life.

When I got to the office yesterday, there was the usual wait, but I was petered out from the blood draw, so I basically sat there in a silent stupor, occasionally complaining that I was bored. Although I brought a disk with MRI pictures on it, I got fresh bilateral ankle X-rays once I was taken in. It’s been a while since I had X-rays taken, and they are so much easier for me to interpret than MRI pictures. Just like his words, “you have end stage arthritis,” the films were as clear as day to me. The articulation between my talus and navicular, the talonavicular joint, is completely arthritic, full of bone spurs and cracks, and has zero remaining joint space between the bones or cartilage. In his words, “this is as bad as it gets.”

We talked about possible mechanisms of injury that would have caused such an advanced disease state in someone as young as me. It might have been the late sequelae of a traumatic injury, the product of an inflammatory disease (like rheumatoid arthritis), or a genetic defect of the bones, which caused grossly premature breakdown to the point of failure. I’m not actually sure which of these was the cause of my resultant end stage arthritis. My hunch is that the first one, a traumatic injury, occurred while I was training for my second New York City marathon, which I ended up not being able to run. I saw a podiatrist at the time when pain around the navicular bone flared up during training, but after some x-rays, he determined I was fine and encouraged me to keep running. I chose not to do the marathon race but kept running. I don’t remember prolonged or severe pain, but perhaps it was worse than I was able to perceive. That was eight years ago. Either way, it didn’t sound like there was an overt injury at that time, since nothing was yet detectable on radiographs.

Whatever the cause, the result is the same: the joint needs surgical intervention. No amount of medication or shots can mediate the pain and debility at this point. It’s also beyond the point of being improbable by a simpler debridement arthroscopic surgery, where essentially, small incisions are made and the surgeon does his best to clean up the joint, perhaps removing bone spurs, smoothing out rough and frayed cartilage, and shaving down particularly anatagonistic surfaces of adjacent bones. He said I’m past the point that that more conservative surgery would afford me any benefits in terms of pain relief or partially-restored function. As he said, “all we can do with such advanced damage is go in there and fuse those bones.” Essentially, I have to get a talonavicular arthrodesis. He opens up my ankle and smooths out the abutting surfaces of those two large bones and joins them together with a plate and screws, turning them into one immobile bone. This will eliminate the chronic severe pain that currently occurs with every step as my foot bends because the joint at the bone would no longer exist. Because the bones no longer move relative to one another, all that scraping and grinding together stops.

It’s not all a bed of roses however. (Who would want to sleep on a bed for thorny roses? It sounds so painful! I don’t know why that saying means something wholly lovely or positive; it sounds dreadful to me (so maybe I should say it IS all a bed of roses, in this case!).) Fusing the bones does eliminate the joint and hopefully the pain, but in rendering the joint obsolete, the natural motion at that joint is lost. Our feet have this structure for a functional reason. The talonavicular joint in the primary joint at the junction of the ankle and foot that allows the motion of eversion and inversion of the foot, the side-to-side motion that allows the foot to conform to changes in the topography of the walking surface. Without this motion being permissible, I’ll have an inability to stand, walk, or run on uneven surfaces (grass, trail, cambered roads, and even normal turns on to a different road).

My function will forever be changed. The surgeon was upfront in the debility the fusion will cause in terms of athletic function and the ramifications this will have on my running. As I stated at the full-size image of the internal bony architecture of my whole foot and listened to his reasonable assessment of the situation, I found myself needing to tune out a bit for self-preservation. My image screamed to me the devastating truth that my days as a runner are numbered. Whenever my mind started acknowledging that, my eyes would fill with tears. I so desperately wanted to appear stoic and mature at my appointment, as if only gathering the objective information without weighing the emotional impact or providing the doctor a window to it. I know at one point he saw into my soul though, my vulnerability exposed. We had a brief, raw eye-to-eye connection and in that instant, everything that needed to be shared was exchanged both ways: he knew I was hurting with the news and I knew he cared.

I felt very comfortable with the surgeon and confident in his diagnosis, treatment, and ability to perform the said operation. He recommended a CAT scan of the area, which is like an x-ray on steroids. This will give him more clarity about the exact condition and arrangement (derangement) of the talus and navicular bones. He thinks there’s an unhealed chronic stress fracture there too, which he would fuse as well. After I get the CAT scan tomorrow, we will meet again, using the additional information gleaned from the better imaging to personalize and specifically-tailor the details of the proposed surgical intervention to me.

He already told me it will be at least six weeks non-weight-bearing on crutches, followed by six to ten slowly weaning out of a boot. It’s a major surgery. The ultimate purpose is to remove the constant pain I’m in and hopefully restore pain-free walking. The running outcome is bleak.

1 Comment

  1. Have you had the surgery yet?? What were your results? I am going having the same surgery next week. I am so tired of being in constant pain, with every darn step. I used to run and miss it terribly I am curious if I will be able to run on a treadmill, play tennis etc.

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