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Peroneal Tendonitis/Tendon Subluxation?
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By Josh Janes
Jun 25, 2012
This is happening to me. Anyone else have positive results with treatment? Surgical vs. Non-surgical?

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By JSH
Administrator
Jun 25, 2012
JSH @ home  photo courtesy of Gabe Ostriker
Hi Josh,

My left peroneal tendon subluxates, as a secondary injury from breaking my calcaneus a year ago.

My ortho surgeon said that some people do fine with it for years, others don't, and there is a risk of rupture.

Personally - I'm waiting and seeing, while I'm still in the process of PT and strengthening. I know the surgery is another 8 weeks on crutches, that's just how long soft tissue takes to heal. So I'm putting it off until I *have* to, and I won't know that until I'm a bunch stronger yet. My surgeon is fine with this approach.

I've been climbing so far in my old Kauks, which are the stiffest things out there. Last week I ended up in some regular shoes, and I definitely had a few problems with the peroneal.

As usual, a PT can give you good theraband exercises to strengthen.

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By David Rivers
Jul 4, 2012
East Beach bouldering
Josh and JSH,

I've had problems w/the peroneal tendon for 20 years, due to a fall in Josh. For the last 10 years, I thought the pain was due to a necrotic spot in the Talus bone, but after discovering trigger point therapy this spring have tied it to the peroneal muscles.

Trigger point massage brings immediate relief which can last for hours to days depending how active I am. Trad climbing aggravates the area more than vertical to steep sport climbing.

This spring, I bought a home ultrasound device for a different injury. It seemed to help speed healing greatly over the typical predicted healing time. I used it once so far on the peroneal tendon and muscles and had longer lasting relief than from massage alone.

The Trigger Point Workbook by Claire Davies is a good resource. Ultrasound devices are as cheap as $100 online. Self treatment in combination w/a good practitioner produce the best results in my experience.

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By Josh Janes
Jul 4, 2012
So the verdict with mine is pretty typical peroneal tendon "retinaculum" tear. Poor outcome w/o surgery, excellent outcome with surgery. JSH, it sounds like mine is a bit worse than yours, but maybe yours is masked by the more significant problems you've had with your ankle? In my case, unfortunately, there's no "wait and see" - it's a must-operate situ. But it should be a pretty simple fix.

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By JSH
Administrator
Jul 5, 2012
JSH @ home  photo courtesy of Gabe Ostriker
My retinaculum is torn too. I'd guess I've just spent so much time walking weirdly this year, and working on my gait, that I got used to it more than what would happen after a more acute injury. I have an ultrasonic thing at home - might pull it out.

Josh, what did your surgeon say in terms of time on crutches, and in a boot? This is a big deciding factor for me; right now, I just can't stomach the thought of more crutch time (after 6 surgeries this year, wheelchair, walker, etc, etc) so I'm more willing to try to work with what I have right now; I'm sure you know what I mean. And how did you injure yours, was it one incident or a chronic thing, or leftover from your own big fall?

My surgeon did say it's a pretty straightforward fix.

Julie

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By Josh Janes
Jul 5, 2012
Julie, this entire past year the attachment point of the retinaculum (lateral malleolus) has been achey, so I think there was some chronic inflammation. This could be due to any number of reasons (my big fall, ACL surgery last year, who knows). But the actual rupture occurred during a routine rock over move on "Forbidden Zone" a few weeks ago.

According to my surgeon, every time my peroneal tendon subluxates, it gets shredded (it's already shredded), and it's only a matter of time before it ruptures which will make things a lot worse. That, and, my tendon subluxates during fairly routine movements (walking or even stretching my ankle) and when it does, it is rather... painful. So, surgery ASAP.

Apparently my particular bone structure (high arches and no groove in the fibula to accommodate the peroneal tendon) makes me pre-disposed to this kind of thing, but during the surgery they'll deepen the groove and at least, according to my surgeon, it should never be a problem for me again (he said I'll be more confident with that ankle than my uninjured ankle). 4-6 weeks recovery time - NWB.

Sorry to hear about your messed-up limbs Julie. My body seemed totally overuse-injury-ache-and-sprain-proof until my big fall... now it seems to be very pissed off at me.

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By JSH
Administrator
Jul 6, 2012
JSH @ home  photo courtesy of Gabe Ostriker
You're reminding me that I really should get it done before I blow the peroneal. Sigh.

Best of luck with yours. Where are you having it done, in NYC? I'm moving to eastern PA in a few weeks, so I'll be looking for a new surgeon if (when) I get mine done.

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By redlude97
Jul 6, 2012
I have/had peroneal tendon subluxation in both ankles now. I tore the retinaculum on each ankle on seperate occasions. On the first ankle I tore it over 3 years ago, lived with it for 2 years before scheduling surgery, and tore the retinaculum on the other ankle 4 days before surgery. They fixed the new tear and it is 90% better after repair which included a bone block. I still get some minor intrasheath subluxation on the repaired ankle, and it is definitely still tight and lost a bit of ROM. 8 weeks on crutches, 12 weeks before I was walking seminormally, at which point I started climbing with a walking boot on. about 4months before I started toproping without a boot on, and 6 months until I started bouldering on it. Recovery isn't trivial.

As far as the nonoperated ankle, it still pops probably 1-2 times a day on average, and over the years the popping has gotten less painful. There is always still a chance of rupture, and I can't run on it very well but walking/hiking are fine. Can still climb on it but jamming is out. Controlled movement is key. Taping/bracing doesn't work, but is can become manageable. I'm not planning on having surgery on the other ankle any time soon and would rather just deal with the limitations.

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By erik rieger
From Gold Hill, CO
Jul 12, 2012
Had peroneal tendon subluxation almost three years ago now. I tried for a few weeks to go the non-surgical path but it seemed dismal, not to mention painful as hell. I did the surgery.

I didn't think it would be a big deal, according to the ortho as well. Had my retinaculum repaired and artificially stapled down and a new groove drilled in my bone. 8 weeks on crutches, one in a boot, lots of PT, and I was still able to make a Bugaboos expedition 5-6 months out from surgery. Pain was bad till about 8 months time and mobility terrible. I was always worried it would pop out again, but that was just paranoia.

I'm now climbing as hard as I ever had, no pain in my foot after I was a year out from surgery but I'm positive I'll never have the same mobility/stability as before, and I believe constant attention to peroneal tendon health is pretty important following the surgery.

Good luck, you will be back to "normal", just don't expect it to be an easy road.

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By Dave Bacon
Sep 6, 2012
Look's like this thread is a few months old, but I wanted to throw out my experience:

I had my peroneal retinaculum ligament torn at the end of April. I was bouldering and doing a standard rocker move putting all my weight onto my right foot and as soon as I rocked the weight my ligament blew (loud pop). I could walk on it right way and it didn't swell too bad, so I just iced and elevated for about 3 days, but I noticed the subluxation feeling and that just didn't feel right. I saw my primary doc who did know what the deal was, 2 weeks later I saw an ortho and he said he was "pessimistic" it would heal on its own, but I tried a light aircast anyway for 3 weeks. No one bothered to do any imaging - that is the first step - get the MRI and figure out what exactly is going on. Didn't get better. Went to another ortho for second opinion (after MRI) and he said I had a 50/50 shot of healing but put me in a metal boot for 6 weeks. Didn't heal.

Finally after months of not being able to do any activity I got the surgery 3 weeks ago. I just had the retinaculum reattached (they put in absorbable bone anchors drilled into the bone and tied the anchors to the ligment). I didn't have to do any groove widening. Surgery was easy and I only had to take ibuprofen after (although they still provide Vicadin if you need it). I woke up in a cast and had the cast cut off 2 weeks later and was put into a metal boot. I started weight-bearing very lightly with crutches after the 2 week mark. I have my first PT appointment today (3 weeks post op).

My advice - get the surgery as soon as you can. I wasted 2 months between not getting the right advice and not sucking it up and doing it when I knew it was the best option. Success rate is well above 90% and they told me, conservatively, I could bike 8 weeks post-op and that I should be back to full strength bouldering 6 months post-op.

Good Luck.

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By jim best
Mar 20, 2013
aahh, back in the day on Shockley's!
aahh, back in the day on Shockley's!



Loving the commentary on retinaculum experience. Hoping your surgery went well, JSH, Josh, red, Eric, and Dave ... and would like to hear how it's come out.

I weakened mine 2 years a go with a highball fall onto rough terrain, and then tore it when I rolled it playing baseball last summer. I tried the strengthening path and it is now fine for biking and flat street walking but pops on any kind of trail and gym climbing. I don't dare take it out trad climbing or skiing. It pops many times a day just walking around and feels generally unstable but not painful.

Girding myself for surgery. Any opinions about podiatrists v. orthopods doing surgery? Infection rates? Is it unanimous that those who have gone the surgical route have no regrets? Any pre-op conditioning suggestions? Thanks!

jim

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By Josh Janes
Mar 20, 2013
Every time it "pops" the peroneal tendon is moving over your lateral malleolus - maybe it'll be fine, maybe it won't (liken it to a rope under tension dragging across a sharp edge?).

In my case (just a couple dozen pops before I had surgery) and my peroneal tendon was already shredded. They were able to repair it though.

Deepened my (non-existant) groove and reattached the retinaculum. This was last July (I was then non weight bearing for a month). I climbed 5.13 in January, but the real test will be how it does at Indian Creek. Noticeable loss of mobility (inversion) and weakness, but I'm glad I had it done.

Having a podiatrist do this operation sounds crazy to me but who knows.

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By Alex Washburne
Mar 20, 2013
I eat crack for breakfast.
Josh Janes wrote:
Every time it "pops" the peroneal tendon is moving over your lateral malleolus - maybe it'll be fine, maybe it won't (liken it to a rope under tension dragging across a sharp edge?). In my case (just a couple dozen pops before I had surgery) and my peroneal tendon was already shredded. They were able to repair it though. Deepened my (non-existant) groove and reattached the retinaculum. This was last July (I was then non weight bearing for a month). I climbed 5.13 in January, but the real test will be how it does at Indian Creek. Noticeable loss of mobility (inversion) and weakness, but I'm glad I had it done. Having a podiatrist do this operation sounds crazy to me but who knows.



Hey Josh!

I had the same injury and received the same treatment (retinaculum repair and deepened groove). I climbed one-footed while wearing the boot (TR is better than bouldering for obvious reason) and when they set my ankle free I started doing the recommmended rehab while watching Rocky montages. I got more than a full recovery - now, my previously injured ankle is indestructible!! I call it my android ankle.

Hope you have a similar experience, and I hope you bask in the joy of being able to climb again at the creek!!!

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By Dave Bacon
Mar 20, 2013
Jim (and all),

I'd recommend the surgery sooner rather than later. My only regret was not doing the surgery sooner. Josh's analogy of a rope under tension dragging across a sharp edge is a good one. The more damage you do to the peroneal, the longer your rehab will be.

I'd opt for a orthopod over a podiatrist. I saw 3 different docs before choosing mine (My wife is a nurse, so she knew a surgical assistant that had seen each actually perform the surgery, so I ultimately went with his pick). Pre-op prep - watch your diet more than anything - there isn't any strengthening you can do. Since you need the right nutrition to recover and since you won't be as active, just be aware of that in your diet.

Post-op, just do everything they tell you to do. Do the exercises. It sounds simple, but this is where most people can screw it up. Just listen to your PT and spend a lot of time on the bike.

I have some soreness after a heard climbing/bouldering session in the gym, but nothing that hinders my abilities. I'm as confident doing the same moves with the same power as I was before the surgery.

Good Luck!

Best,

Dave

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By sarahd
From Lakewood, CO
Mar 11, 2014
Red Rock Canyon
Does anyone have an ankle surgeon in the Front Range that theyíd recommend?

I dislocated my ankle 7 weeks ago when I fell and hit my foot. The MRI showed subluxed peroneal tendons and possibly a longitudinal split in the peroneous brevis. My tendons havenít moved over the lateral malleolus since the injury. However, the non-surgical route seems to have a high chance of re-injury. Iím also lacking a groove in the fibula, which makes me pre-disposed to this type of injury. Iím hoping to get a second opinion and find a good surgeon. Any recommendations would be greatly appreciated.

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By Josh Janes
Mar 11, 2014
If your tendon hasn't subluxed since the injury I'd definitely get a second opinion and consider the surgery carefully. In my case it has not been without some significant long term (well, I'm two years out from the surgery) consequences.

But I can recommend Dr Leland at Mapleton Hill Orthopaedics.

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By Dave Bacon
Mar 11, 2014
As I mentioned in my previous post, I saw 3 separate docs before going with surgery. I saw Leland first, my general impression (and my wife's, who is a nurses in Boulder) is that he is a very good surgeon but he seemed a little pushy with surgery. I got a second opinion from Dr. Shonka at Foot and Ankle Care of Boulder. Because of my case/age/athletic ability, he though surgery wasn't necessary and i spent 8 weeks in a boot. My opinion was that his bedside manner was better, I also know he is a great surgeon, but I needed the surgery so his initial assessment (FOR MY CASE) was off.

When I still had issues after wearing the boot I saw Dr. Stephen Paul at Boulder Orthopedics. I would recommend him to anyone. He was a great balance of between Leland and Shonka. Most importantly, I know a surgical assistant that had actually done my surgery with Paul and he was extremely impressed. I was sold.

Hope that helps and good luck with your decision. Anyway you do it, make sure you don't come back too fast - be patient.

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By Josh Janes
Mar 11, 2014
So my long term side effects have been perpetual minor swelling, peripheral nerve damage (no sensation around my lateral malleous) and a general aching/pain where the retinaculum was reattached especially after hard climbing/hiking. The first two issues are merely annoying but the pain issue is upsetting. Anyone else who had the surgery have similar experiences? The subluxing is fixed and I've gone on to do my hardest climbing and hiking ever since the surgery.

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By Josh Janes
Mar 11, 2014
Oh yeah, and a vericose vein in my calf - but this is my second major injury to my left leg so it was probably bound to happen...

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By sarahd
From Lakewood, CO
Mar 11, 2014
Red Rock Canyon
Josh and Dave,
Thank you!! This is great information. Leland is the doctor I have seen so far and I also got the impression that he is very pro-surgery for this injury. My laymanís understanding is that even though my tendons havenít gone over the lateral malleolus since the accident, they are not in the correct place (They are on top of one another). That problem, combined with a potential split in one of them may be causing on-going pain. Itís hard to know how long to deal with the pain before getting surgery... Not to mention the constant wonder of when/ if I will re-injure it.
Josh, I hope your ankle pain goes away.

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By Josh Janes
Mar 11, 2014
All of my complications were a direct result from the surgery itself. However, in addition to pain I could not walk let alone climb after the injury, so I had to do it. Only you can make the decision about what to do - but it might be good to get a second opinion. I just wanted you to be aware that a groove deepening procedure and all the soft tissue repair that might be done is a pretty major surgery - not to mention what being non-weight-bearing will do to you.

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By jim best
Mar 11, 2014
I am so thankful for these posts! You all helped me make the tough decision about going through with the retinaculum repair. But the results posted here seem pretty positive. Josh, sorry about your pain and numbness deficits. But then again, climbing 5.13 on it probably softens the downsides a bit ;-)

My podiatrist at Kaiser Permanente did the surgery 2 weeks ago. I, too, was skeptical but that's all they do is ankles. And that's how KP does it. They built my trust. Was off pain meds in 3 days. But no weight on it for 6 weeks and then 4 more until I can start real PT. A long haul but I think a good investment for the next decade. I'm 62.

On a 5 mile hike (mild terrain but 1500' uphill) the longus would sublux 50 times (without pain). I can replace it mid-stride. It was flat instead of round. The brevis was permanently subluxed. Both had sinovitus (inflammation). But no pain. I could not trust weighting it on trad climbs as it would pop disconcertingly. In the gym it was OK if I could hang on one arm and pop it back but it kind of crimps one's style (even mine). Hurt to weight it with the longus subluxed.

I got right knee surgery (debriedment) 4 months ago to support my recovery of the left ankle. Glad I did! The podiatrist took another MRI the week before the ankle surgery. She removed the peroneous quartus muscle and tendon and a low-hanging lobe of another muscle to give more room for the peroneals to run. Based on the second MRI she decided to do the groove. She removed the sinovitus around both tendons and sutured the retinaculum using holes drilled in the ankle bone. No bone blocking used. Then she sewed the flattened tendons back into rounds.

I'm really interested in your long term experiences (6 months, 1 year, 2 year, 3 year etc.) and I'll post mine. If this forum gets lost I can be reached at best.jim@gmail.com. Sorry for the long post. Good luck!

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By Dave Bacon
Mar 12, 2014
I think Leland is a great surgeon and to his credit, he was right about being pushy about the surgery. I was 28 and thought I was still pretty invincible, so I think I was just shocked that was the correct thing to do. It sounds like he is giving you good advice.

My experience - My retinaculum was torn doing a pretty standard move bouldering. I had a leg out on a ledge, rocked all my weight up and onto the ledge and it blew under stress. I walked on it right away to see if it was broken and it seemed functional so I didn't get it looked at right away. After a week and a half noticing it was sublexing, I saw Leland and tried an aircast on the ankle for 3 weeks. No help. I saw Shonka, got an MRI, bone grooves looked good, but retinaculum was definitely torn. I tried a full boot for 8 weeks. No help. I saw Paul and had the surgery. Mine was relatively minor, my peroneal was in good shape and my groove was deep enough, so it was just a retinaculum repair. I was on pain killers for the day after surgery and then I just opted for ibprofen. I was non-weight bearing for 2 weeks, partial for 1-2 weeks and then full weight in a boot for 2-3 weeks. Rehab was tough, but I was diligent about it (I went to Boulder Sports Med). Stationary biking was the best and I still do it regularly. I was very diligent about rehab because I was supposed to be scuba diving in late-december and my surgery was late august and I was worried about finning with a new ankle. Turned out fine.

I was climbing 4-5 months after rehab. Physically I was back bouldering 6 months post-op, but mentally I still didn't trust I was back. I would be pretty sore after a good session. I was back on V5 and mid-to-hi 5.11s comfortably (mentally and physically) 7-8 months out.

I'm a year and half post-op now. I am back climbing V6-V7 and mid-5.12 in the gym without any side effects during or after. I do spend more time in the weight room (lifting and preventative stuff) now then on the wall and have more strength in my legs then ever and I think that has helped. The only time I notice my ankle is on weird weather changes - but I also notice other old injuries when the weather is weird.

All our injuries vary in severity and subsequently in recovery, but all sounds positive. These posts were very helpful for me during research since it seemed like a rare injury there wasn't a whole lot out there. Thanks for everyone's posts, good luck to everyone moving forward.

Best,

Dave

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By Dave N
Jul 21, 2014
Hi Everyone,

I think I have the same problem: peroneal tendon subluxation

I wish you all are fully recovered, and speed recovery for those who are not.

I had a fall, popped and swollen couple years ago, I didn't see a doctor at that time, just rest and ice, and ankle seemed to be fine; did x ray back then and no problem as no pain too. then I went to see a Orth. Dr and he diagnosed me may have peroneal tendon subluxation with ultrasound device. Told me eventually I had to do surgery in order to fix this.

Every now and then the dislocation or subluxation happened when i walk or stand too long, or if high pressure on my foot or ankle. or when I squat. It doesn't hurt in a way.. I can also easily move the "tendon" back and forth.

I haven't gone to check MRI and still looking for good ankle and foot specialists or surgeons in New York.

I am extremely worried about the pain, cost, complication and mental depression after the surgery. Wish you can help me out,

How much does it cost to do the surgery? also the PT?
The pain, is it really unbearable? or how you manage it? how long did you think you are pain free?
any complication? still pain? popping? any other side effects after 2 years?
as the depression, i am really worried or depressed now :(
Also when did you start taking bath? 2 weeks after surgery?
Anything I need to prepare in advance for the recovery? as simple as knee walker? or bath chair??

Thanks in advance and much appreciates for your help

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By jim best
Jul 21, 2014
5 months since my surgery. A good time to weigh in and give my experience and maybe give answers to Dave N's new questions.

I am doing great with the left retinaculum surgery as described in my last post. It feels more solid than my right ankle (which I tweaked rolling up on a hold a couple years ago but it never fully subluxed). I am climbing 5.11b in the gym but mostly held back because I tore my distal biceps tendon off the bone while recovering from the ankle surgery and they had to plug that back in as soon as I got into my walking boot and off crutches (another story later!).

I just got back from a 2-day hike to the summit of El Cap from Tamarack Creek in Yosemite (8.5 mi each way, 1800'el gain). No problems with the ankle at all.

I have had some trouble being a good convalescent. I got a knee scooter for the house with the ankle in the cast and fell over 3 times whipping around the corners. Way fun! Get one. So much better than crutches. Get a DMV permit authorized by your surgeon for disabled parking. I fell flat on my face coming in from the street when I caught both of my crutches on the curb and they flew out of my hands. I tore my biceps tendon protecting my head on another fall with the scooter. In this last couple months out of the cast and boot I had to be cautioned to take it slower. I pretty much followed their guidance at that point. My biggest regret (besides the bicep) was that I actually tweaked the ankle on a slackline (I know, in retrospect that sounds so stupid but I was doing it just fine for more than a week). The ankle felt so solid I lulled myself into thinking it was invincible. That really got my attention. Chalk it up to inability to delay gratification, poor judgement, and not trusting the PT and surgeons who have a vested interest in being conservative to keep their work from getting messed up. I have to say, taking it slow, at their pace is the best medicine, at least for this 60-year-old. The ankle was better after a few days but the whole thing still feels a bit fragile, like I don't want to make any fast moves to the sides. I'm careful climbing and placing my feet. I haven't climbed outdoors.

So Dave N:
  • No clue on the costs. My insurance covered it (Kaiser Permanente).
  • No pain for me since I injured it 2 years ago. Surgery pain is typical, being painful for up to 4 or 5 days but the meds take care of it. Alleve after that for a few days then off.
  • No complications from infection or anything else. The tendons slide freely. Swelling was for a few months but not really that bad. I got a compression stocking for a couple weeks but didn't really need it.
  • No popping. Only side effect for me is the reduced range of motion. It doesn't bend forward as much as the other. But on the uphills it just means my heel comes off the ground at a less steep angle than for the other foot. Note that my expectations are those of a 60-year old who has had his play. Ask a 20-year old if they are satisfied with the results for perspective.
  • Baths - shower after 2 days, sponge bath before that. I have a tub and just sat on a plastic stool and hung my mangled body parts over the edge. Casual.
  • Prep with conditioning your hamstrings & quads and calves and such but you will lose your muscle in that leg. No way around it I think. Get pillows for keeping your leg a little higher than your heart for several weeks. I have a loving partner that covered for me my part of the housework and such ... but mostly I wanted to do things for myself when I could.
  • Depression - hell yes. But once I made my decisions about going for it it was like a Grade IV or V. You just do what you have to do and it feels good and empowering to be moving forward to a better place. There is always the fear you will go off-route, or get hit by rock, or take a fall, or ... but you just go, no? And mostly what I got out of these posts at this site is that people come out better by far in the end. You shift your view from the worries of a 2-day or 2-week or 2-month time span to the longer vision of health and activity. All the sweat around those worries becomes trivial and fades. Maybe it won't work out but the chances seem better than those you take on a climb on a regular basis. Just do what you need to do to walk freely again!

Good luck!


shower technique ... support crew
shower technique ... support crew


this is getting ridiculous!
this is getting ridiculous!

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By jim best
Jul 21, 2014
Not sure if this will get past the censors ... graphic pix of the retinaculum surgery of my ankle. It's gruesome but kinda cool. Remember, this work was done by a podiatrist ... 4 years of medicine and a residency. She had to be in her early 30s and played catcher in college softball so she knows what it's like for someone to be on the bench.

High praise for this (un-named for anonymity) surgeon at Kaiser Permanente!
left outside ankle, toes to the left ... flattened...
left outside ankle, toes to the left ... flattened peroneous longus and brevis, overe the yop of the ankle bone instead of behind it ... should be behind the retinaculum, not in front of it


removal of the peroneous quartus muscle to give mo...
removal of the peroneous quartus muscle to give more room for the tendons to nestle behind the ankle bone ...eh, who needs it?


tendons sewed back into cords and ankle bone marke...
tendons sewed back into cords and ankle bone marked with purple marker line for drilling ... she may have grooved the ankle bone at this point to get more room for them


tendons in place, holes drilled, ready to re-attac...
tendons in place, holes drilled, ready to re-attach the retinaculum ... this is difficult to explain without a drawing but she has slit the retinaculum vertically and it's drawn back like a shower curtain on either side of the bone ... she will take the right half and pull it over the tendons and tuck it under the bone, draw the left half over the drill holes, and then run sutures through the topside to the bottomside of the ankle bone catching up both pieces of retinaculum ligament and locking them to the bone ... the tendons slide in the tunnel she has created

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