Ankle OCD Microdrilling - Recovery Questions

[DanDaMan]

Hi,

Great forum, but very depressing as well.  Hoping for some hope from folks on here!

My story:

* Avid runner pre-diagnosis: 45 minute 10k, 21 minute 5k runner - 43 years old, very fit (6'1", 150 lb)
* Ankle pain started in Dec 2011 after clipping a curb on a run.  Was later diagnosed with medial talar dome OCD (8mm x 2mm x 3mm ... 2.7 cm in the transverse direction [?])
* Got ankle scope on July 31 2012, removed lesion (defect looked like a "bubble") and did microdrilling
* ~ 1 week post-op, with zero pain (only took one painkiller at the end of the surgery day as a precaution) -- just some expected fatness/swelling inside the dressing and splint toward the end of each day
* Doc is planning on moving me to weight bearing boot ~ 2 weeks post-op, and believes I'll be running again in 2 - 3 months
* Doc said that 85% of these surgeries are successful within 6 months.  Yes?

Questions:
* How bad of a lesion would you characterize mine (see above)?  Apparently not bad enough to do OATS or more invasive surgery, but bad enough to do microdrilling.
* Any specific positions I should be putting my leg before moving to boot, in order to promote the best formation of fibrocart?  I am crutching around NWB just fine (up/down stairs, sitting normally a lot [desk job], and propping it up a bit as well, and even doing 30 - 50 pushups/day with all weight on my good leg/foot!)
* Any specific diet recommendations (drinks/food) to promote the best possible healing of the microdrilling?
* Does anyone have a success story from an OCD microdrilling that resulted in returning to a normal running routine?  Seems like most cases out here are not very good outcomes; just looking for some hope, since I have been an active runner my entire life and it's how I keep my sanity in the face of day-to-day challenges.  The doc is VERY optimistic, and I was feeling the same until I read some of the posts on this forum.

Thoughts?

[sead]

Hi Dan
From what I understand how bad your lesion is depends on a few things
1- where on the talus it is
2- size( yours is too small for OATs etc) OATs etc are for when you have no cartlidge
And 3- what the damage to the cartlidge or bone is
I am also was a runner but can no longer run but that is because when they went in to do the scope my lesion had no cartlidge left on it but it sounds like you do- oterwise i don't think you would be moved into a boot so soon
I was no weight bearing for 2-1/2 months!!!
My lesion is approx 1 cmm but like I said there was no cartlidge left
I think that it sounds like you will be running again!
My surgeon did tell me to take vitamin D and make sure that I was getting enough calcium in my diet
Although i can no longer run i am hoping to be able to backcountry ski, hike, climb, bike, scuba etc
I wish the best of luck and hope that you are running soon
Sead

[DanDaMan]

Thanks Sead.  My first follow-up post-op is on Monday ... basically two weeks after the surgery.  The splint seems to have done fine - I have no pain (that I can tell) and can even move the ankle joint around just a small bit inside the dressing/splint just to avoid being completely stiff once it comes off.  But obviously I will be nervous putting weight on it, which I assume I will be trying tomorrow when the doc tries to move me to the walking boot.

For medicines, all I did was take the Toradol prescription (for 5 days), then one Aleve (200mg) since.  Other than that, I haven't felt like I needed to take any anti-inflammatories, so hopefully that's a positive sign.

So, I guess I'm still trying to understand how bad this lesion was?  Any thoughts on this?

Location : Medial Talar Dome
8mm x 2mm x 3mm
2.7 in the transverse direction (what exactly does this mean?)

He told my wife that the lesion looked like a bubble, so the cartilege was there but had become disconnected from the bone (hence the bubble).  So I assume he had to remove that cartilege to do the MF, yes?  Anyway, lots of questions for the doctor...

[sead]

Hi i am not sure that they remove the cartlidge if it is disconnected- they drill so that it will reattach I think. My cartlidge was frayed and thin and missing parts so they removed then drilled. To try to create a cover * fibrocartlidge.
Yours sounds like a bruise on an apple. A much better kind of injury  to have than mine.
I think that if your doctor thinks that you will be able to run in a few months it sounds as though you will. Lesions that are bigger than 1 cm is considered larger but the kind of lesion is also important- damage to bone, cyst or no cyst( arthritic changes) etc etc
Your situation sounds positive- Good Luck!

[DanDaMan]

Thanks.  I was moved to a walking aircast on Monday and have been walking with no crutches (most of the time), and doing range of motion exercises with the ankle a few times per day.  Resistance exercises will start in 3 weeks.  I have a desk job, so I am spending most of the day sitting with my leg in a normal position.  But I do stand up quite often and walk around on it throughout the day.

The whole foot/ankle's pretty swollen at the end of each day (probably from sitting so much and walking on it), so I'm propping it up before dinner and icing it for 30-45 minutes.  I will start taking two Aleve (440mg) around lunch for the next few days, just to see if that helps with the swelling.  Sometimes I feel some weird sharp pains (briefly) when walking with the aircast, but overall - it doesn't seem to be too bad so far.

The swelling is freaking me out a bit, but the PA said that I would have swelling and that it would hurt.  So I'm trying not to panic this early in the recovery.

In speaking with the doctor and reading the OR report, it looks like he did decide to remove the disconnected cartilege, smooth over the edges of the lesion to keep the rest of the cartilege in good shape, then he did the microdrilling in the medial lesion (the pictures show the blood leaking out of the bone from the drilling - lovely).  He also did some "cleaning out" of the lateral part of the ankle, because it had been a bit swollen/irritated from the lesion itself for a few months.  The report says that he removed membranes and stuff ... not really sure what it means, but he told me that he cleaned out the rest of the ankle and the rest of the joint looked great.  What's interesting is that I have more discomfort on the lateral side of the ankle, even though the microdrilling was for a lesion on the medial side.  Guess the "clean-up" work also requires healing!

I assume that somewhat heavy swelling is pretty normal at this stage of the game, especially since I'm walking on it with the aircast (no crutches) and sitting down for a lot of the day?  Anything you'd do differently given your experience?

[sead]

Hi Dan
Like I said I was a runner too- my lesion is 1cm so slightly bigger than yours
I was non weight bearing for 2 and 1/2 months then PT
It is now 6 months and I can bike ride and walk with some pain and swelling but getting better daily- still limping at te end of the day
But I also had a ligament shorteming which is healing well
I was told that I can never do any running or any other kind of impact sport again - i was wondering if the difference is that you had an impact and that your bone was not involved at all??
My bone is supposedly good but there was some slight  pitting or cystic changes before  mocofracture
Swelling so soon sounds ok- swelling of some sort expected for up to a year in my case
I know that if I still have pain in january which will be 11 months since microfracture they will do a special kind of CT scan and then another microfracture as bone needs to be covered by something
Saying that maybe your lesion is in a spot that does not have any impact when you walk or run?? I would like to understand this more but surgeons dont seem to be the best communicators
I still think that if the surgeon says you will be runnng again there is no reason to suspect anything different

[DanDaMan]

Hi,

Great question - I'm not sure about the location of the lesion and whether it is considered an impact-bearing part of the talar dome.  He only said that it was on the medial side of the dome, was less than 1cm, and needed surgery since I was having symptoms after my runs (note that I felt GREAT during my runs <sigh>).

Anyway, I am now into the 4th week post-surgery and still in the walking aircast.  I only use crutches in the middle of the night if I need to get up (cast is off when I go to bed).  I still have a decent amount of swelling and "soreness" on the lateral side of my ankle ... it has that "ankle sprain" look, and it feels pretty sore when I do range-of-motion exercises.  So far, no resistance training until I'm out of the walking boot.

The swelling/soreness on the lateral side is concerning me, but I know that the surgeon "cleaned stuff up" in that area of my ankle.  He said there was a lot of irritation in there that was caused by the medial talar dome OCD, so I imagine that I'm still healing from the clean-up work that he did.

It's hard to imagine ever running again based on how I feel right now, but I'm only 3+ weeks into the recovery, so I know it's too soon to know.  But I will keep folks updated on this thread as my recovery continues.

Thanks -

[jmPT]

I had MF on my medial dome of the talus on april 11th of this year and my results are not as good as yours but I am happy you caught yours relatively quickly and are recovery well. I was toe touch weight bearing for 3-4 weeks. Then was able to place more weight into it. It feels weird, I know. It gets better. The swelling my be b/c of your job. Even if you are elevating it at work, your ankle is still below your heart. For proper elevation to truely help with swelling is for you to be laying down with your ankle above your heart (and icing it). Because of the position you are in (sitting at a desk) the fluid cannot work up the venous system as well. The elevation you do at work is better than nothing. If possible, lean back in your chair and prop your foot/leg up on your desk for 15-20 mins every 2 hours with ice. I don't know you situation so it is hard to give good advice. Also, with any elevation, do ankle pumps. The calf muscle helps pump the fluid out of your ankle/foot. Due to the size of my OCD (17mmx8mm) my microfracturing did not work and will be placed on the bone donor list. I still have mild ankle swelling expecially after a long day at work. I am a physical therapist and on my feet ALL day.
good luck!

[DanDaMan]

Thanks!  Really helpful feedback, and I appreciate it.  I have a technology consulting job, so I spend a good deal of time either sitting at a desk/table, or standing and walking around conference rooms, etc.  So icing in that environment is tricky, as well as elevation.  But overall, it does seem like the swelling goes down by a very small bit every day .... I think.

I am now 5 weeks post-op and had a follow-up with the doc today.  He took me out of the boot and tested forward/backward resistance of the ankle (not bad, but definitely needs strengthening), moved it around a bunch and did not detect any clicking or popping of the joint, etc.  He said that the ankle looked great and that the swelling that I had looked fine for 5 weeks post-op.  Next steps for the next 6 weeks [until 3 months post-op]:

* No more walking aircast unless I have to do a lot of walking (go to a football / baseball game or something)
* Biking and/or eliptical cardio w/ resistance as tolerated (yay!  I am anxious to burn some calories and breaking a sweat again)
* Forward/backward resistance exercises
* No side-to-side resistance exercises at this point (he said it could interfere w/ the MD healing process)
* Calf stretching

We will see what the next 6 weeks brings.  He said that we won't really know if the MD worked/failed until I try to start running again at the 3 month point ...

[DanDaMan]

JM and others -

For those who have been through this MD procedure ... at what point *early in the recovery* do you know if it was a success or a failure, or if it's at risk?  And as part of the recovery process, how do you know if you are pushing the ankle too hard vs. not hard enough?  I got mixed messages from the Doc and the PA, and now I'm in a bit of a panic at 2 months post-op ... thinking that I might already have a failed MD.  Any feedback from your experiences would be greatly appreciated:

Here’s what I started doing at 5 weeks post-op at the specific direction of the surgeon/doctor (after my f/u appointment where he examined and tested my ankle and made sure was was no popping, tracking issues, or other big problems -- all seemed fine):

•   Started alternating between cycle and elliptical with mild resistance (~ 2x per week for ~ 20 minutes)
•   Started regular left calf stretching as prescribed
•   Started Theraband resistance exercises as prescribed (~ 2x to 3x per day) <-- no lateral resistance, only forward/backward movement of the ankle with the band
•   Got rid of the walking aircast – limp is pretty much gone, but I do have some mild pain/sensation that feels lke it's near the microdrilling site (hard to tell exactly).  It might be getting a little worse, but I'm not sure.  It's actually starting to feel the same as it did BEFORE the surgery.  This is starting to concern me, but I spoke to the PA yesterday and she just told me to 'take it easy' and seemed to feel that the routine above was a lot (even though it's what was specifically recommended at my 5 week f/u).  Note that I'm not using the aircast and I pretty much have full range of motion restored.
•   Ice and elevation 2x/day in the evenings
•   Aleve 440mg 1x/week [each Saturday, since I’m doing a decent amount of walking on the weekends]).  No aircast, and the ankle feels really good when the Aleve kicks in.  Overall, though, I'm trying to avoid taking an NSAID because I want to gauge how much the ankle swells daily (to see how the recovery is coming along).

Questions:

1.   At around 7 weeks post-op, I have started feeling some mild sensations (Pain maybe?  Hard to tell) on the medial side where the MD was done (starts not long after I wake up and start walking around), and I still have a decent amount of swelling throughout the ankle during the latter part of the day.  Nothing seems serious, but I don’t know if the healing process could be at risk.  Is this to be expected?  If I'm getting sensations/pain around the MD site at 2 months post-op, does this mean that it's probably already failed no matter what I do, or am I just pushing it too hard?  Swelling is fairly pronounced around the ankle my mid-afternoon each day.  Is this to be expected?
2.            At my 5-week f/u, the doctor specifically said that I shouldn't feel pain when I start the day.  And for the first couple of weeks after that appointment, things seemed to be cool.  But now, here I am this morning and I am feeling some pain in the medial area (only have done some walking around the house), so does this mean that it's failed?  I'm in a bit of a panic after starting to feel this over the past couple of days... 
2.   I live in a 3 level home, so I’m walking up/down stairs a decent amount throughout the day – full range of motion and no aircast.  And I figured this would be good for strengthening.  It's actually felt pretty good doing this until the past couple of days days ... and now I'm starting to get this pain/sensation around the medial side of my ankle.  The doc said it would be okay for me to do that stuff (and use my manual transmission automobile [left ankle]), so clearly load bearing stuff was expected to be fine.  But when I spoke to the PA yesterday, she seemed to indicate that stairs were not a good idea because 'we don't want load on that ankle'.  Huh??!!

Thanks in advance for any thoughts and feedback.....

[jmPT]

Hey Dan,

First of all BREATHE!!! Don't friek out too much. I understand b/c I did the same at 8 weeks. I will try to answer your questions, from my current experiences, the best I can.
1. My Dr said he would decide if my MF/MD scope was a sucess at 5 months. It takes 8-12 weeks for a regular bone (i.e. arm/leg...)  to heal after a break, so think of it like that. My Dr told me the fibrocartilage the procedure tries to stimulate take a little longer. At the 5 month mark if you are still having pain, then you can get a little worried. Try to breathe.

2. I was told to gradually progress my activity as tolerated. If it hurts-->stop it. If you are walking up and down the stairs  during the day..... I would not be worried about using an eliptical. I would stick to a bike and not standing up on it and peddling-- like a spin bike. THis would be overloading it. I would limit the amount you go up and down the steps. It is alot of loading onto the area. Try to decrease the amount of trips by waiting until you have 2-3 things to do up there. for example, wait until you have to do something on a higher floor and bring the laundry up then. Try to stay on one level as much as possible. Also, don't run up/down. go slow, use your railing for a little support. If it is hurting and you have to use the stairs, step in this pattern: step up with the good leg and step down with the bad leg. It is a step too pattern. The Reciprocal stepping up/down may cause too much loading onto the ankle. The saying I tell my patients at the clinic to remember this is: "the good go up to heaven, and the bad go down to hell". (I live in the bible belt  and it works well here. ) Your PA is right, take it easy. I don't  know when you went back to work, but my dr told me he usually has ppl with desk jobs to take 4-6 weeks off and then back to work for 20 hours a week for 2-3 more weeks. I am on my feet all day and lift patients so he kept me out for 10 weeks and then 2 weeks of 20 hours and then progressive to 40 hours over the next 2 weeks. When I was out, my couch was my best friend.
The theraband activity is fine- It is not weight bearing and will not hurt the joint. Try calf stretch non-weight bearing by sitting on the ground-legs straight out in front of you, knee extended and use a towel hooked on your forefoot and gently pull into stretch.
The NSAIDs- take them when you hurt or swell. it helps the swelling and the pain will go down and you won't limp. when you limp, you are actually changing you biomechanics in the joint and can cause increased pain in the joint. I talk tylonol or advil PRN/per package directions. For me mostly at night and sometimes I take something in the afternoon. I'm not a dr, so the best thing is to ask your dr what is best for you.

3. the swelling could be b/c you are doing too much and your job (I think you said you work at a desk). Try to elevate. I had mild swelling until 3 months. I'm at 5 months now and I think i still have some slight swelling.
I had some pain free time also but as I progressively went back to work, I started having pain again. Unfortunately, my procedure has failed. I just had another MRI and see my dr on monday for a decision on what to do now. I had the "options" conversation last week with him. He is debating b/w an OATs with a plug from my knee and taking the medial wall of the talus out and replacing the meidal dome completely with fresh cadaver bone--b/c my defect is very close to medial wall and might not be strong enought to hold a plug. 

I hope this helps 

[DanDaMan]

Hey jm,

Yes, this helps.  I really appreciate you taking the time to share your insights and experience.  I am desperately trying not to freak out or panic at this stage ... I guess I just want to get back to running so bad, and discouraging thoughts have entered my mind.

Everything you mentioned sounds good -- I've been doing stairs in a reciprocal pattern (and it seems to have been fine), but I'm going to let up as you suggested and take the more conservative approach.  When doing the bike or elliptical, do you think it's okay to use some mild resistance, or is the purpose at this point just for range-of-motion?  The Doc said resistance would be fine, but the PA said no ... so I was really confused.  I haven't been pushing it at all -- in fact, I don't even come close to breaking a sweat during the 20 minutes that I've done a bike or elliptical.  The calf stretch idea is excellent; I'm going to try that out as soon as I finish writing this post.

I am really sorry to hear about your MD outcome, but you seem to have a really positive attitude which is inspiring to me.  Because of the size of the lesion, did you know "going into" MD surgery that it might not work?  What were the chances the doc gave?  I was told 85% success rate at 6 months, but for some reason I'm just not buying it.

Thanks again jm - I hope you receive some promising options for Plan B next week ...

[jmPT]

Thnaks for your encouragement Dan! I have to stay positive. I have a 2 and 4 yr old and I have to remember that I WILL be able to run and play with them the way I would like too soon. Getting depressed about it is not going to make a difference on mine or your outcome, but over doing it WILL. The reason the eliptical is not a good idea in my eyes is that it is constant loading on the surgical area. I would stick to the bike- you can probably do resistance on the bike without a problem. Think about it, standing verse sitting- which one places more weight into your ankle? For exercise- try toning/weight loss yoga. It can kick your butt. Plank position stinks after 30 second holds and works the entire body--- also if you have an exercise ball  (the big ones), there are alot of non-weight bearing exercises you can do- this stuff might not help your endurance but it can keep/increase your strength--- just a thought.
BTW, i'm a physical therapist so I do understand alot of what the drs are thinking of and I know what I would tell one of my patients if they just had surgery 8 weeks ago. You have a lifetime to stand on your ankle- you just had surgery 8 weeks ago. you walk and that will stimulate growth. if it hurts=stop- your bone is telling you something.

With my % of sucess my dr told me at the time of surgery--- well going in he was iffy it would work b/c of the size and chronic nature of my defect. when he went in I had ALOT chronic synovial linning inflammation inside the ankle joint. It looked like white cotton candy all over the inside of the joint. (I was awake for the surgery, thank you epidural- so I got to see it for myself) He cleaned it up and he thought at the time the inflammation was causing alot of the pain and he thought I had a good 90% chance of full recovery... I kinda knew better b/c I know the kind of pain I was having. Remember- this is my second time around with this. the first was 13- almost 14 yrs ago when I had a chip floating in my joint-->got it pinned down--> now chip died and erroded away leaving my defect. I knew prior to the MD that I was in for more surgery.
Ill let you know how monday goes!

[DanDaMan]

Hi all,

Just wrapped up my 3-month post-op f/u with the surgeon today.  I'm still getting some pain/swelling throughout the day (worse in the evenings), and had some pain in the microdrilling (MD) site that seems to have subsided this week, but I've only taken a couple of Aleve over the past several weeks in order to avoid the use of medications for reducing swelling (icing only), so that could be a factor.  Here is what happened in my 3-month f/u ... would love to get opinions from others:

* He did a round of x-rays and said that the MD site is filling in exactly as he would expect at this stage.  He specifically said that the MD site was already 50% filled in as compared to the lesion at pre-op, so apparently my ankle is already in a better place than it was before the surgery (although the aching I still get makes me question that).  He assured me that he was able to see this from x-rays and didn't need an MRI to make this determination.

* He said that I have no bad swelling anymore; only some very minor surgical swelling

* At 2 weeks post-op, he moved me off NWB crutches and full weight bearing with the boot.  Then at 5-weeks post-op, he moved me out of the boot and had me walking full weight-bearing with theraband resistance exercises, and some light biking (which I've been doing, and walking 100% of the time, but with good/bad weeks re: pain and swelling).
At my 3-month appointment, he tested my ankle strength and balance and said that I was looking good, and now wants me to go every other day with the following rehab routine for the next 3 weeks, then evaluate:

-- Odd days: 10 minutes walking, followed by 5 minutes slow jogging (just one rep)
-- Even days: Biking with resistance (said that I could start resuming some real cardio and bike up to 25 miles on even days)
-- More stretching and theraband (forward/backward ankle pumps only, no lateral movement exercises)

His whole methodology (as compared to other stories on this site) sounds so aggressive and dangerous to the success of the MD procedure, so I asked him specifically about it.  He is an accomplished sports medicine guy, and he ASSURED me that his experience (and studies) have shown that moving patients to weight bearing and range-of-motion sooner (for me, at the 2 week point) promotes better healing of the MD site than staying on crutches and no ankle movement for 6-8 weeks+.  He was extremely confident in that statement and has been trying to assure me that starting the light jogging routine at 3 months isn't going to damage the healing process, etc.  Just trying to compare this statement with others' experience on this board.  What are your doctors saying?  He did say that he was making this determination based on the severity of my lesion (which he's never really described to me in detail, but I shared the dimensions from the MRI in an earlier post in this thread).

I must admit that I'm anxious to engage in the rehab routine immediately, and I tried it right after the doctor's appointment by heading to the gym and doing 10-min walk + 5-min jog on the treadmill, but clearly my ankle felt weak and was somewhat painful when I tried the jogging part, so I only went for about 3 minutes.  Today is the next day I'm supposed to try it ... I have to trust the doctor and do this, since I'm runner, right?   At the moment, I'm going to just take it really slow and maybe take a little more Aleve over the next 3 weeks while I work on this rehab.  Just as long as I'm not damaging the success of the surgery ... he assured me that I won't be doing that.

Just curious re: any feedback others have from their experiences.

Thanks -

Dan

[sead]

Dan Hi how is your ankle?
I am still confused about the whole OCD thing- such different directions from doctors! I have very little info from my doc!
So are you running? I had my surgery last feb 23 and am able to walk without limping and have gone for short hikes and biked - it is still weak but is getting better every day. I will ski this winter but going downstairs is still a bit sore. My doc says no running because the fibrocartlidge is not as strong as regular cartlidge and will wear out quickly - so he said no impact sports at all.my lesion is a little less than 1 cmm and like you did not hurt when I ran but after a few longer runs became extremely sore
Also he told me that the only way to tell if the fibrocartludge grew or filled in is by going in with a csope agian or getting a very specific kind of CT scan- he tole me that an xray will not show cartlidge fill
I am very curiuos about your results and am wondering if I can run or not- i really dont want to wear out fragile fibrocartlidge? Did your doctor tell you that it would wear put?
Sead