Week 6
My Boot – This week as I start to weight bear I should comment about my VACOped boot, which I think is fairly unusual for most patients.
I have had this ever since I woke up from surgery 6 weeks ago. It replaces all forms of plaster cast, and then a walking boot. Right from the start I was able to get a bit of ankle movement as there seemed to be enough space in the boot to wiggle a little. I could also get my foot out to clean, massage and scratch. I can only imagine what six weeks fully immobilised in plaster does for your skin and ankle mobility. It is heavy at just over 2kg, though perhaps that adds to the efficacy of passive exercises. It was really just at night that I found it a nuisance but hopefully in a week or two I can take if off overnight. In those early weeks though it kept my ankle at a right angle to prevent the achilles contracting again, and risk damaging the tendon transfer by overstretching it.
The boot comes with 2 terry liners that contain an microbead insert a bit like a bean bag. When you remove the air in the insert with a little hand pump the liner hardens to conform to the shape of your foot and leg and is supposed to give it extra support. There are 4 straps that you can adjust as feels appropriate, and slacken off a bit if resting with your foot up.
To begin with the ankle was locked but this week I have had the stops adjusted to give 15 degrees of movement and this will be progressively increased until I am walking in the boot with full weight bearing and a full range of ankle movement.
It still seems traditional to have a plaster cast for most patients. In the NHS the cost of the boot probably restricts its use, but this was just added to my bill and was only a small part of it. Most private patients still seem to have plaster also, but perhaps ask your surgeon if you have a choice as the manufacturers claim that this boot will speed your recovery by at least a couple of weeks. From the patient viewpoint the ability to look after your skin, particularly around the incisions and to be able to keep your ankle and foot flexible whilst it is healing, must be a very major advantage over a cast. Although I have mentioned I had up to 5 cm of calf muscle wasting I can now report that has now improved to a 2.5 cm deficit now. That I guess is down to the early hydrotherapy.
I think the company started in Australia but a link to the UK distributor is here, and they have a video of a pretty amazing champion windsurfer recovering from a repeat fractured ankle.
The VACOped boot is much bulkier than a shoe, especially with the heavy duty sole that is more than an inch thick. You will therefore walk rather lopsided which doesn’t help gait or balance so they do an ‘evenup’ foam sole that straps onto your other shoe to raise it a bit. Oddly this isn’t part of the kit you get with the boot which I find rather odd as it is an essential accessory. When I get walking properly in it I will upload a video so you can laugh at my efforts.
Driving – Suprisingly I haven’t missed my beloved car as much as I thought I would by now. I am lucky in that I have an automatic and its my left foot involved. The rules from the DVLA are clear, no driving at all of a manual car with a orthopaedic cast or boot of any sort on either foot and you can only drive an automatic if its your left foot only that is immobilised. The risk for pedal confusion is just too great. Even so the size of my boot means that even with it up against the left side of the footwell it only clears the brake pedal by an inch.
My first tentative drive was just up to our local supermarket in the village centre. No problem and had my 2 crutches in the passenger seat. On the way back to the supermarket car park, using the shopping trolley as a zimmer frame, I met a work colleague whose wife had just had a similar operation a few days beforehand and so he was out shopping for her. Must be more common than I had thought. Mental note to ring her up and offer encouragement.
Week 7
January 25th – I have my next outpatient review with Mr Malik for x-rays and hope to be able to get more advice on getting back to work etc..
I am swinging confidently on 2 crutches now but my foot out of the boot still feels very weak and vulnerable. I had quite a few x-rays taken and a lateral weight bearing film which was interesting to compare to my original films. The pre-op film is the one with the lines on it and there shouldn’t be that much of an angle between the line of the talus (under the anke joint) and the line of my toes. On my new film this line is much straighter and the arch is restored.
My ‘too many toes sign’ has also resolved, see the before and current photos here indicating that my forefoot has been re-aligned. Still noticeable calf wasting but have regained about a half of what I lost.
The emphasis now is on progressive weight bearing. I am now to just use one crutch when around the house or just walking short distances and progress to walking in the boot without crutches in about another 2 weeks. The foot of my VACOped boot was unlocked to now allow a full range of ankle movement. The other great news is that I no longer need to wear my boot at night, which I am really pleased about. I will though need to use it whilst walking around for another 4 weeks or so.
Back to work: I need to make plans now for a phased return to work. Conducting outpatients clinics will be the first part of my job that I can return to and I hope to start these in a week’s time. Walking around seeing patients on the wards will be more difficult and the unpredictability of managing emergencies does not seem feasible for me at the moment. Before I can return to doing surgery I need to be able to stand on my left foot comfortably to be able to use both hands. I don’t think the sight of a one-legged surgeon leaning on his crutch is going to give my patients any confidence. I do have good team support, so am confident that it will go smoothly. Mr Malik impressed on me that a phased return to work is important and I need to have time to continue my physio appointments and rehab exercises.
If honest though I have now had a bit of a taste of a less pressured life so it would be good to think about cutting down a bit in due course. One of the nice things about medicine is that you don’t have to fall off a cliff at retirement but can adapt your role and job plan, service permitting, to scale down for the last few years. The NHS can ill afford to lose its senior doctors, either in hospital or general practice, through burnout so they need to be accommodating to keep us engaged, and productive in the later years of our careers. Often that doesn’t seem as clear to our senior managers as it should be, especially when the service is under pressure and overly focussed on targets, rather than on the quality of service that we are providing.
My goals for the next 6 weeks: So what am I expected to achieve over the next month or so? This is the next section from the plan, we will have to see how I measure up to these in due course.
Recovery Rehabilitation Phase (6-12 weeks)
Goals:
- To be independently mobile out of VACOped boot
- To achieve full range of movement
- Tendon transfer to be activating
- To optimise normal movement
Restrictions:
- Ensure adherence to weight bearing status.
- No strengthening against resistance until at least 3 months post- operatively
- Do not stretch transfer. It will naturally lengthen over a 6 month period
Treatment:
- Posture advice / education
- Mobility: ensure safely and independently mobile adhering to appropriate weight bearing restrictions
- Progress off walking aids as able once reaches full weight bearing stage
- Gait re-education
- Wean out of VACOped boot once advised to do so
Exercises:
- Passive range of movement (PROM)
- Active assisted range of movement (AAROM)
- Active range of movement (AROM)
- Encourage isolation of transfer activation without overuse of other muscles.
- Strengthening exercises of other muscle groups as appropriate
- Core stability work – balance / proprioception work once appropriate
- Stretches of tight structures as appropriate (e.g. Achilles), not of transfer
- Review lower limb biomechanics
Address other issues as appropriate:
- Swelling Management
- Manual Therapy: Soft tissue techniques as appropriate
- Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise
- Orthotics if required via surgical team
- Continue hydrotherapy if appropriate
My Flatfoot Surgery Recovery 