June 15, 2011

Predictive Of Failure

I haven't even logged into my blog since the day I posted my video almost a full month ago, and now that I'm here I'm struggling with what to say and how to say it.

It's been a long month, period. The entire process has been much more difficult than the first time around and the numbers can crush my spirits when I think about them...by the time I hopefully get off of these things again I'll have spent six of the past nine months on crutches, and that's the best case scenario. That fucking sucks. No matter how I attempt to spin it, it's just upsetting for me to think about. Given that I was on these things for three and a half months the first go around, and I am already four weeks in this time, I should ideally have less than six weeks to go, but as before it's one x-ray at a time right now, and again that's the best case scenario. I am currently refusing to process the worst case scenario.
(I'll specifically reference these xrays below)

Did I have surgery?

Why the hell not? Am I stupid?

I automatically assumed that once my foot faltered for a second time that surgery would be the best course of action. I think the majority of people believe the same thing. We're programmed to. As a general rule we are taught through many mediums to place surgery ahead of natural healing. To place modern medicine ahead of naturopathic/eastern medicine. We look to pills to solve everything in today's age and 'putting a pin in it' is not the instant solution everyone believes it to be.

I sat down with my surgeon for over an hour on Thursday May 19th, having already booked in for surgery the following morning. He had me slotted for a fifteen minute consultation, assuming I was simply signing the paperwork and going about my day. I had questions. Lots and lots of questions. I was not afraid to have the surgery, it's a fairly straight forward procedure, I just needed to know if the potential benefits of the surgery made sense. I wasn't about to have a screw put into my foot without knowing the facts, and here's where an additional frustration lies...

Everyone seems to think they know what's best for you without even having the slightest insight into the nature of the problem. A Jones Fracture is not 'just' a broken foot. It's one of the most complex single fracture lines you can sustain within your foot, and as such no matter what course of action is chosen recovery is quite difficult. If one more person tells me to take a calcium supplement I'm going to impale them with a crutch, upload their picture to every social networking site on the planet, tag them with their own name and many additional four letter descriptors, and threaten to eat their children a la Mikey Mike, Hall Of Fame, Tyson (I've had a bone scan and it's come back as 100% good)

I spoke to the surgeon for a solid hour and not a single answer provided to me was conclusive. Most were 'ifs' and 'maybes' and 'most likelys' but the words that were never uttered no matter how the questions were phrased were:

Surgery 'can be the better option for some people in some cases', but conversely that also means that 'non surgical healing can be the better option for some people in some cases'.

My thoughts when I broke my foot again in Hawaii was that I would obviously miss Western States on June 25th, but with surgery, six weeks sidelined, and a few months back on my feet I might just be able to make the starting line of UTMB in France on August 26th (yes in hindsight I now know how ridiculous this was). The estimated time line presented to me for recovery from surgery was 10-12 weeks. THREE MONTHS! That's what I just went through without surgery...why am I not hearing any benefits here??

Will the foot be conclusively stronger?
No guarantees

Is the recovery time significantly shorter?

Is it any less likely to refracture again?
No guarantees

I drove home (don't ask) and was completely uneasy about the whole thing. Surgery was now twelve hours away and nothing felt right about it. I did a bit more research and when I found a few specific studies around elite soccer players suffering from Jones Fractures my mind was effectively made up for me:

The return to play following a Jones fracture continues to be an enigma for the competitive soccer player. Caution and patience must be applied since re-injury to this area is common. Potential types of re-injury include a fracture with deformation of the screw, incomplete bone healing or non-union and compensatory injuries to the foot from the altered biomechanics. There are inherent risks with competitive sport and the athlete should understand that the Jones Fracture, even when repaired can create significant disability...

one must remember that this fracture site has a characteristically poor blood flow. Consequently, its healing rate may be slower than other types of fractures and the new bone may not reach peak strength until much later post-operatively...

Also, the traditional guideline of letting pain direct activity progression is not infallible because the athlete may be pain free or there may be only very minimal pain prior to re-injury. There are also many adjacent joints and bones that may generate a pain response due to disrupted mechanics or contact from the screw head

And Another Report
          - out of 15 people who had surgery there were six treatment failures: four refractures and two symptomatic non-unions
          - there was a higher proportion of elite athletes (division I or professional level) among the failure group (83%) compared with those without complications (11%)
 - return to full activity, especially among elite athletes, before complete radiographic union was predictive of failure

And this was WITH SURGERY!!!

I called off the surgery immediately. My summer was over anyways. My racing season was a wash. There was no rush. I needed a few days to come to terms with it all.

Hadn't I been counselled with 'pain as my limiting factor'? Wasn't I told that I should be good to go? Could all of this have been prevented? Would I have even listened at the time and really slowed down anyways?

There was a lot weighing on my mind, and none of it was made any easier by feeling like I was repeating my story to people every five minutes. I know the questions were coming from a place of genuine concern and caring, but I just did not want to talk about it. How could I when I was still so uncertain on so many aspects of it myself?

By the end of that first weekend I was confident I'd made the right decision. Knowing what I'd gone through the first time round had given me slight insights into what might and might not work. Back in late December early January I had an immediate healing response once I introduced regular acupuncture and ultrasound. As mentioned in a report above, lack of blood flow to the area is the number one complication in the healing process. I immediately referenced my friend Kim Graham at Thrive Total Fitness and began getting acupuncture 2-3 times a week. I unfortunately had no luck in attempting to land an at home ultrasound device this time around.

I had viewed enough x-rays of my own foot by now that I was certain what I'd seen in Hawaii was not quite as severe as what I'd seen way back in September, and then on my follow up xray in December. On top of all this, my foot itself looked completely different. The first time around the swelling continued right into my HURT trip, ten weeks out. This time however there was very little swelling initially and virtually none within the completion of the first few weeks. I requested a follow up x-ray here in BC on May 31st.

The x-ray on the left was taken two weeks post fracture in Hawaii. The x-ray on the right, SIX weeks post fracture in Oregon (travel insurance is your friend)

You don't have to be a Doctor to clearly see that although I definitively re-fractured the exact same line of my foot, it is not as severe as the initial break was. There is still some integrity to the initial healing process.

A few things can be taken from this, as reiterated by my own Doctor/Surgeon (and I should clarify that he's been great throughout this entire process). Given that the x-ray on the right was taken six full weeks after my initial injury and had yet to even begin to adhere to itself at all, there was serious question as to if I would in fact be able to naturally heal the bone. It's actually quite common for people to not gain union of this fracture through natural avenues and THEN surgery becomes the only real option. Some people still do not gain union of this bone even after surgery. It's a shitty situation no matter how you slice it. 

So What Does It All Mean?

-Because I have recovered from a more severe version of this already there is no reason to believe that I won't be able to do so again. I WAS on the right path to a full recovery if I'd only been counselled slightly differently from the start
-PAIN is NOT the limiting factor in a full recovery from a Jones Fracture, TIME is
-Once I do get back onto my feet running will be seriously limited for an extended period of time. Vive le bicyclette, but Lance is going down
-The world is a nicer place when you're on crutches, people actually care, but I'd still toss em tomorrow if I could
-If The Canucks lose in game seven at home I'll join the looting just for the hell of it. Put in your pre-orders now but keep in mind it will need to fit into an average size backpack
-I think they should cancel Western States this year because of all the snow and roll over all 2011 entrants into 2012
-UTMB should be postponed until at least December so as to avoid a possible mudslide like last year, PLUS covering the course in the winter would be way cooler...and I only mean that literally
-WHAT the hell is Jersey Shore and WHY the fuck are they on TV? Seriously? I just got cable for the first time in over two years
-There are no shortcuts in life and Lebron James epitomizes what's wrong with our way of thinking in North American society. No professional athlete wants to take the time to build a franchise into a winner anymore, everybody wants weight loss and happiness in a magic pill or potion, and the majority think that surgery is an easy fix. It is not.

It's one day at a time right now, one foot in front of the...err...one foot in front of, uhh, itself I guess? Over and over and over again...

PS Here's the song you should definitely have in your head on your next run. You're welcome



Anonymous said...

I'm not an expert, but it seems to me that they can always put a pin in but once it's in, it's in... I'm sure I would make the same decision! I hope your recovery is faster this time!!!

Here's a perfect song for when you can start running again:

Are you still coming down for WS?

All Day!

Aaron said...

Calcium supplements are such a waste of money. I think the current consensus is that a balanced diet which is low in phytic acid and includes enough leafy greens is the best way to improve bone density. I assume that means it also helps fractures heal faster.

Paul said...

Heal well Gary. Need i say that the reason for this failure could well have been your sudden increase in mileage once you got the ok. Actually- it was ridiculous!

Maybe this time take it easy. Less mileage. More healing. More acceptance.

Get well soon dude.

Instant Classic said...

Good luck Gary. I myself got a Jones fracture playing basketball on May 3rd. Had surgery on the 13th and am still in a cast. Reading your post will definitely make me slow down my return to full activity. I think I will officially defer my registration for the half marathon I registered to run on 9/11 - well before my injury.

After viewing my x-rays last week, I have become a bit worried about non-union. Hopefully things look better when I go back on the 29th.



garobbins said...

I should clarify that I certainly wasn't insinuating that surgery is wrong or indeed not the best option in a lot of cases. Here, for me & me alone, it made no sense at all.


wiglebot said...

I am with you on no surgery. A pin in your foot is different than a common case. You could bend it or break it charging down a skree field.

I broke my foot 2 times and the the pain was not in the build up to the second break because I don't have nerves to sense a minor stress fracture getting worse. It only hurt once something happened. Maybe checkup X-rays will help?

You are a natural endurance athlete, that is not changing.

Adrienne said...

wow- enjoyed reading that. Each person preaches their own craft (eg. surgeons preach surgery). You're very wise to do your own research and make your own decision. You really can't go wrong with your decision. Good luck and hopefully have fun (bikes are very fun) through the healing process!

Anton said...

F***ing hell, man. Reading this is painful. Totally agree on your WS/UTMB date-change suggestions. Stay positive and heal up.


dvroes said...

Thanks for sharing all of this. I can only imagine how difficult this is for you (in every way). Best of luck in your recovery.

Instant Classic said...

No worries Gary. I didn't take your post as an indictment of surgery. I read all the same articles and decided the other way. Both choices are obviously viable. My doc is being very conservative so I don't think I'll be rushing back anyhow. I've been told after x-rays on the 29th I MAY be put in a boot and MAY be allowed partial weight bearing. It's definitely not a clear cut decision that at 6-8 weeks you are on both your feet again.

I wish us both a speedy and full recovery. I can't wait to ditch these crutches.



Sean Kelly said...

Hoka One One. I know you guys are sponsored but just try these things and see if Karl and Dave Mackey don't know what they're talking about.

Jenn said...

Hey Gary,
I think you had a bone DENSITY scan, not just a bone scan.. a bone scan indicates bone activity (which should be positive or "hot" in a fracture, as that means the bone is healing).
And, maybe not specifically calcium can help, but there is research to support OTHER supplements aiding in bone fracture healing.

sorry about the canucks losing.. hope you didn't get tear gassed...


Love your personal research! Its great to see someone make 'educated' decisons. You WILL heal, and some day in the future you'll be training your ass off, longing for those day's when you had time to relax on the couch, and time to do whatever you want... is there a course you always wanted to take, but never had the time? Just sayin'

Hoppy said...

G.man ,had surgery on broken finger from mtb. crash , pins installed result= It screwed up my hand for good !.I went off the doctors recomendation at the time that surgery was totally necessary. Afterwards when it was obvious i'd lost range and mobility he casualy told me that finger joints are very unforgiving, WHAT!?. Each injury being very different of course ,but if i had the chance again for this particular injury ,against majority rule, it would be No fricken surgery! . Be patient, stay on course, you'll heal. How did your crutch swag heist go ? and thanks for the Milli v. ,smoking was even good for you back then, your image that is. alohas

Bill said...

Wishing you a speedy (but most of all thorough) recovery. Sorry about the Canucks too, but I hope the looting was fun.

Anonymous said...

Hey Gary, I'm always impressed and inspired by your blog..Whatever you're doing, you go all out. And again, in researching the surgery option. You're a leader even when injured!
Heal well! Cheers,Jill

Bipolar Boy said...

Hope your foot heals well. I can feel how pissed you are in your post but as usual there's still that Gary Robbins sense of humour. As a fan of yours and of coach Kens' podcast i would love to hear you on there again as they are just the best to listen to.

Get Well,


Anonymous said...

hmmm. I must be different, I say replace all bones with carbon fibre, inject blood with massive amounts of EPO, and as much happiness as money can buy then spend away. That's my plan for my 2012 victory over your fractured, self healing yogic body. We'll call it Lebron vs. Dirk '12!

Deanna Stoppler said...

Dude, I'm sorry to hear that. I am rooting for you, as always. Totally sucks, in my opinion.

Sean O'Day said...

Gary, I suffered a Jones fracture in October. Many of my ultra brethren immediately piped in and informed me that you had done the same thing. I'm an ultra runner and blog junkie anyway and had read some of your stuff, but it's taken me over three months to get around to reading it. Why? No clue. Mostly because I was scared of what I would find.

Anyway. Nothing else to add. Some of us were just following along to see how HURT was doing - one of my buddies, Brandon Stepanowich - is running it now too, and saw you're doing well. I figured I should suck it up and see how you got from your second break to leading HURT in less than two years. Maybe I can glean something from it.

garobbins said...

All the best with your recovery Sean!