Chris Ferguson

Like any good consumer, I thought it would be important to gather information about this surgery before it was done. I found many web sites each containing vivid pictures of parts of the foot and brief descriptions of pre-surgical treatments and the surgical options. Many of these sites used the exact same text and pictures as the others. I didn’t find ways to prepare myself or my home for this event. I’m sure others have had this same experience, so this document is an attempt to share some of my preparations and experiences before and after foot surgery.

However, it’s important to remember that this was my personal experience. Not everyone will have the same needs or context. I live by myself, so this definitively influenced some of my preparations and actions.

My problem was fascitus or more specifically that the fascia was too tight; therefore, every time the foot was flexed, the fascia irritated the area where it attaches to the bone as it wasn’t long enough to stretch the required distance. The correction for the problem is to lengthen the fascia. I tried exercise, physical therapy, anti-inflamatories, cortisone shots, orthotics, casting, ice, and night splints—then considered surgery. In reality, I let the pain become almost disabling before I considered one of the two surgical options. I kept thinking if I just worked hard enough that one of these methods would work.

The surgical options for this problem are both outpatient surgeries, and both have an expected hospital stay of 4 to 6 hours. The doctor described both procedures and the positives and negatives of each. One is more invasive; one is less. I have now had both procedures. This paper is about the open release surgery or the more invasive surgery.

The first surgery was Endoscopic Plantar Fasciotomy (EPF). The doctor cuts two very small incisions, one on each side of the foot. The surgery is done through a small tube that is pushed through the incisions, using video for visualization. The best thing about the EPF surgery is that the "invasion" of your body is limited. The negative side is that it does not offer the surgeon a full view of the fascia and surrounding tissues; therefore, the doctor can only address problems in a limited field. Unfortunately, I was one of a small percentage of patients for which this surgery did not correct the problem as there was damage outside of the area that can be visualized.

I have already been asked if I would make the same decision again. The answer is that I don’t know. I have always felt that the more we are able to use our body’s natural healing and non-invasive chemicals or procedures, the better it is for the body. The second surgery, done a little over a year later, was an open release of the fascia. Again, the doctor described the procedure, the possible outcomes, and possible "other things" that could be found in the foot based on the symptoms. The surgeon cuts an incision of about 2 inches on the inside part of the foot in order to fully view the fascia, smooth any bone spurs that might cause additional problems, and further release the fascia as needed.

In this second surgery, the doctor found that the part of the fascia, which had not been visible in the EPF surgery, was tight and enlarged. This was the cause of the continued pain. Though he also explored the surrounding tissues, there were no other problems. I am still in the recovering stages, so I do not know the final outcome of this surgery. However, contrary to what everyone has told me, I find that I am recovering more easily this time. At times, the pain is much more severe, but I can move my foot more easily. I am assuming that is because the fascia has been released enough to allow for full extension which I could not do easily after the first surgery because of the remaining tightness.

Though I found that my doctor was very good at answering many of my questions before asked, I still prepared a list questions for the doctor:

§ Are there actions other than surgery that might prove effective?
§ What is the percentage of improvement with this procedure?
§ What things can go wrong in the surgery?
§ How long will I need to be off work?
§ What limitations will I have when I return to work?
§ How long will I need walking "aides" – crutches/cane?
§ How long will it take to walk "normal"?
§ What kind of pain will I experience?
§ How long will the pain persist?
§ Are there shoe modifications that I will need?
§ What are problems that I need to look for in order to keep from having unwanted complications?
§ What happens if this surgery doesn’t work?

Preparing the House…

Since my house is small, I was not worried about having to move around too much. However, closeness creates another problem, there is not much room to maneuver with crutches. Here is a list of the things done before the surgery.

§ Placed chairs strategically in the kitchen, by the front door, and by the bathroom sink. Since I often rested the knee of the injured foot on the chair or stool, I put a pad or towel on the chair/stool to keep the knee from getting sore.

§ Bought a cordless phone, so I wouldn’t have to worry about "getting to the phone."

§ Placed pillow/s for propping up my foot on the couch, the bed, and on a file cabinet next to the computer.

§ Pre-taped some TV shows for a couple of weeks that I did not have time to watch. Daytime TV is not great!! I stocked in books. I went through my mending and sewing basket as I knew I’d have some mindless time.

§ Took care of the bills, so that I wouldn’t have to worry about them.

§ Bought some quick-fix foods, so I would not be "up on my feet" too long.

§ Found an old trip bag that could be placed around my neck to carry books, drinks and such.

§ Made sure I had a sealed liquid container so that didn’t have to worry about spills when carrying drinks from the kitchen.

§ Bought bag ice for the ice packs as it is much smoother and fits in the ice packs more easily with a lot fewer bumps. I had several cold packs that can be kept in the refrigerator; however, they seem to produce more moisture even when wrapped in plastic. I waited to use them until the incision was further healed.

§ Bought a shower bag to keep my foot from getting wet. It is much easier to use than a trash bag and tape.

§ Placed something in the shower to sit on. Though I looked at shower benches, I chose a milk crate covered with a small towel. It is light, very inexpensive, and moves easily.

§ Arranged for someone to take me to and from the hospital.

§ Picked up a pair of crutches but also tried them out in the pharmacy. Though the sizing was correct, the adjustments were off. The pharmacist helped make the appropriate adjustments. There is a formula for the height of the arm and hand pieces and such.

§ Picked up a cane and followed the same process as I did the crutches.

§ Bought an automatic car (okay, not just because of the surgery, but almost). There is an obvious difference in the amount of use and stress, when you are trying to rest your foot, in driving an automatic versus a standard even in the week before and weeks since the surgery. As a note, I drove the standard car for the first time about five weeks after the surgery—I’m really glad I’ve switched to the automatic. The standard really stressed the surgical site even weeks after the surgery.

These procedures seem to be set up to answer all possible questions and make sure the hospital collects plenty of information. They will ask for

§ List of medications, including herbal medicines that you are taking,
§ If you can describe the procedure you about to have,
§ Emergency contact information,
§ If you have made arrangements for someone to pick you up at the hospital, and
§ If you have a living will.

It takes about 45 minutes to an hour for this interview. Hospital staff will recommend that on the day of surgery you dress comfortably and that you bring as little with you as possible, including money and valuables.

My doctor also recommended

§ Daily vitamins and proper nutrition when in recovery.

§ Rest as much as possible directly after the surgery—particularly for the first 3 or 4 days after the procedure.

 

Since I’m pretty much of a wimp, I knew I needed something for pain. I wanted to use Tylenol whenever possible though. In reality, I took the prescription pain medication as needed only. However, it’s important to note that I don’t feel comfortable with being heavily drugged, and I’m not sure it is really a good idea to have a heavily drugged person walking around on crutches. This does not mean I didn’t have pain; I just tried to take as little as possible. In reality, I probably should have taken more than I did. One of the things my doctor stressed, however, was the combination of Tylenol with the prescription pain medication—too much or poor timing in the doses can lead to liver problems.

I arrived at the hospital about 90 minutes before the surgery. I have to admit I was feeling quite a bit of anxiety. I took a high-interest, low-concentration book to read and my crutches. However, the staff really had a lot to do for and with me. Everyone in the operating room team came by to introduce him or herself and explain what his or her role was in the procedure. I was warned that each person would ask repeat questions. They did. "Have you had anything to eat or drink and when" and "which foot" were the most popular? I have to admit when they put the band around the left foot, and each person checked to see that the band was on the correct foot, I felt much better.

The doctor discussed anesthesia with me. He did not want me to feel any pain in the surgery, so he recommended general anesthesia that would put me totally to sleep. It was also my choice. My son had eye surgery when he was six. The doctors recommended the use of an anesthesia that did not make him oblivious of the procedure, so they could talk to him as needed. Unfortunately, instead of being reassuring, he was horribly frightened. He had nightmares about the surgery for months because things were happening that he didn’t understand. While not six, I didn’t need anything to stimulate my fears.

Truthfully, I remember nothing about the surgery itself other than being taken into the operating room, getting on the table, several questions about how I was doing, and the first injection. Though I don’t know if this is the policy at all hospitals, for this procedure, they strapped my hips to the table and each of my arms to "boards." As this was done, they explained that they did this to keep me from moving during the operation. The next thing I remember is waking up in the recovery room. While I have talked to others who have wanted and used regional anesthesia rather than general, I do not regret not knowing what happened during the procedure. I was incredibly nervous.

The recovery room stay was also fairly uneventful. The doctor did come in and talk to me, but he was very brief as I was still sedated. They gave me oxygen to help me clear the anesthesia out of my system, checked my vitals multiple times, and then sent me on to Outpatient Services once I was fully awake.

Once I was back in outpatient area, I could have water, coffee, or tea. The doctor came by to talk to me about the operation as I was obviously more awake. He was very specific about what he had and had not found. He asked me to be sure to

§ Keep my foot absolutely dry—This is to prevent infection.

§ Put no weight on it until it had been x-rayed—This has to do with the spur removal. One spur needed to be ground off. If there is imprecision in the grinding, putting weight on the foot too soon can cause stress fractures. Before putting any weight on the foot, he wanted to x-ray the foot and make sure there would be no problems. He planned to do this at the first post-operative visit.

§ Rest as much as possible—This is to allow the body’s natural heeling to begin to take place. If you overtire your body after the trauma of surgery, you can slow the healing process. He also recommended that I take pain medication at night to ensure that I received proper rest each night.

§ Lie with the foot elevated 6 to 8 inches above the hips as much as possible—This was to reduce swelling.

§ Ice the foot as much as possible during the first 2 to 3 days, alternating 20 minutes with and without ice during waking hours—This was to reduce swelling. Icing when swelling occurs later was also recommended.

§ Be sure to keep post-operative appointment in 5 days.

Please note that any surgery, not matter how small, is still traumatic to the body. Though some people have the ability to go in, have surgery, and act as they have had a hang nail removed, this is not really the norm. I was incredibly tired. The doctor said I could return to work in 4 to 5 days. On the first day I returned to work, I actually only worked 5 hours.

Let me first say how incredibly uncoordinated I am. I don’t manipulate "extensions" to my body well. In fact, my family has laughed at me quite a bit. Since I also have arthritis in both shoulders, walking on crutches is NOT comfortable. Staying in one place is the best thing to keep from falling on the crutches!!

However, because staying in one place is really not an option, I made sure to scope out possible problems and think about "how to fall." Without crutches, you can just roll to keep from hurting yourself. With crutches, you have to think about how to use them to help, get rid of them if they are in the way, and keep the injured foot from harm. As someone who has now fallen frequently on crutches, I know the moments I have taken to think about my physical location have kept me from hurting the surgical site or other parts of my body other than a bit or bruising. That doesn’t mean I haven’t had hard falls, but I’ve had no injuries other than bruises.

Different doctors have their patients use crutches for varied lengths of time. My doctor asked me to go non-weight bearing for the first week after the surgery, then partial-weight bearing for the next two weeks. Using the crutches is a pain from many perspectives, but it also allows the surgical site to heal more easily. I used a cane for a few days to transition off crutches.

Over the last year, I’ve had way too much experience with pain. Once the pain has set in deeply, it is much more difficult to gain control over it. For this reason, it is important to gauge the pain and react in a timely way. Once the pain is firmly entrenched, it is much harder to control.

Early the second day, my foot was extremely sore with occasional, very significant twinges of pain. While it was not comfortable, it was not debilitating. I decided to hold off on the prescription pain medication until the pain was more constant. I was hoping that it would pass.

About 5 pm, the top of my foot, not the surgical site, also starting hurting. This didn’t make a lot of sense. I continued icing and keeping my foot up. About 9 pm, the pain suddenly moved into overdrive. It was an extreme change in level of the pain. I immediately took the prescription pain medication. By 11 pm, it was not better. In fact, it was much worse. I had not taken the prescription pain medication soon enough to catch it in the early levels. It was in control.

Quite frankly the pain scared me because it wasn’t in a place I expected it to occur. It became a question of whether to the call the doctor. I was not running a fever, the swelling looked okay, there was no oozing fluid or blood on the bandaging, and I hadn’t fallen directly on the foot or hurt it in any way that I knew. There appeared to be no reason for concern, other than pain. I wondered if maybe it was just muscles being held in an awkward position because of the wrapping and such. I decided not to call the doctor at midnight which I’m sure he appreciated. I continued to take the prescription pain medication at appropriate times. The pain finally subsided about 7 am the next morning. I did not sleep all night. When I talked to the doctor later, he said it was more than likely a combination of the swelling (though not hugely swollen) and the wrapping. As my foot had expanded, the wrapping was caught in odd places causing constriction.

Though the pain was significant, the loss of rest was the real problem. I was really low on energy the day after this episode. I found myself winded and irritable doing even the smallest of actions.

I dropped a glass of water while standing at the kitchen sink and saturated my bandages. This is one of the call-doctor-if-this-happens. So even though it was a Sunday evening, I called him. He asked me to remove the wet dressings and use sterile gauze or large sterile bandages to protect the surgical area until the next day. I needed to make sure the surgical site stayed dry and look for infection. If there were any problems, I was to call back. There were no additional problems.

Lying around in bed for days is not my usual habit, or the crutches, or the configurations you get your body into trying to keep your foot elevated and weight off the injured foot. My hips, shoulders, hands, knees, and back were soon very sore. Generally, a couple of Tylenol was sufficient for this discomfort. However, I did check to make sure about the timing in taking both Tylenol and prescription pain medication.

Unfortunately, as you begin to move around and do more, you will cause soreness and some additional swelling. My doctor was fairly blunt with me – the more I chose to do, the more pain and swelling to expect. However, he also stated that as long as the pain subsided with rest that it was unlikely that I had done severe harm to my foot. Since I live by myself, it is virtually impossible not to be active, but I did try to simplify things so that I was up and around as little as possible.

I also found that wrinkles in the wrap, my sock, or any bandaging also led to discomfort, sometimes very severe.

While at home the first 5 or 6 days, the pain came in two forms: intense pain at the surgical site and shooting pain that appeared in odd places at odd times. At no time was the pain constant. I can’t say it was inconsequential either, but it was manageable.

When I began working, the pain increased. Naturally, I was spending more time upright and "on" my foot. I was still using the crutches, but partial weight bearing. The pain was, as the doctor stated, associated with the amount of stress I put on the foot. The first week at work was really tough. The pain did lessen in severity and length after that first week back at work.

A month out from the surgery I walked very slowly. Walking quickly or standing for more than 2 or 3 minutes was very painful. If I shifted weight to my other foot, it also began to hurt from the weight stress on the single foot. I could walk from the parking lot at the grocery store and about half of the first aisle before the pain began to significantly grab my attention. If I knew I was going to have to walk for a lengthy period or be "on" my feet for an extended time, I took the Tylenol ahead of time. However, in both cases if I got off the foot and propped it up, the pain subsided, again, a good thing according to the doctor. The doctor also recommended that I massage my foot as a means of increasing blood circulation and therefore healing.

There was also aching and some severe pain in the rest of my foot as I became more active. I did find that when I massaged my toes and the outside side of the foot I could ease some of the ache radiating throughout the rest of my foot as I began to walk more.

By the end of week 5 after surgery, I was trying to get my life back more into normal—more walking and more movement. When I felt I couldn’t handle the pain, I used Tylenol to curb the pain. Though it did not always fully alleviate the pain, it did make it manageable. I still limited my walking to essential needs.

Six weeks after surgery, I was scheduled for a convention trip. As this was a part of work, I needed to go. I arranged to have transportation assistance in the airports and limited walking and standing as much as possible while at the convention. At the slow pace I walked, airport transportation was essential—I would never have made the plane connections. However, I didn’t do as well at the convention. By the end of the second day (of five), I was in significant pain. Without the prescription pain medication, I would not have been able to tolerate the pain. I did not take the full regiment of doses, but a dose in the afternoon calmed the pain enough for me to do what needed to be done. I also iced my foot around noon and again at night and also wrapped it in an ace bandage at night. By the time I got home, the pain was not better when I got off my foot and propped it up. It was hurting full time. However, a few days after the trip, the pain again eased up after the foot was rested.

Seven weeks after the surgery, I continued to try to be "more normal," though still limiting what I did. I began to use a stationary bicycle. I still avoided lengthy walks or standing for extended periods of time whenever possible. Times when I had to walk or stand for period of time were still painful. The surgical site developed harder ridges beside the incision scar. I continued to massage that area in order to increase the blood circulation and expedite the healing process. I also started to have the shooting pains at odd times again. However, the discomfort was manageable if I was able to stay off the foot for a period of time after "stressing" it.

Eight weeks after the surgery, I felt fairly comfortable on Mondays, the beginning of week, but by Thursday or Friday, I was glad for the end of each day when I could get totally off of the foot. My walk looked fairly normal on Monday, but by Thursday, I had a noticeable limp. There were obviously significant times of pain, but there was also a significant amount of time that was pain free. However, with rest, the pain always subsided.

According to the doctor, this surgery has a slow healing process. There may also be structural problems that will have to be addressed at a later time. It is too early to tell. However, the fact that I can actually bend and flex my foot in a normal way is a first positive step. The fact that each week the surgical site hurts less is also good. The fact that there are longer and longer periods that are pain free is VERY good. Am I going to be totally pain free? I don’t know. Do I think I’m better off for having the surgery? Yes.

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