Tuesday, December 20, 2011

Snowboarder vs. How Fast Was I Going for Real?

It's now four weeks without an update on the ankle.  What's the deal?  Update!

I needed a break.  Dealing with ankle pain on a daily basis for two years can wear on you.  The distraction arthroplasty surgery has, for once, given me that awesome break.  The ankle has felt good enough over the last few weeks to finally forget, momentarily, the last two years.  It still hurts -- just not nearly as bad as it used to!

I now walk without a cane.  I stopped using the elevator last week and I've been hitting the gym regularly.  The ankle arthritis has returned, but it's not debilitating.  I'm still taking 200mg of Celebrex every morning.  The pain is probably around 20% of what it used to be before the surgery.  I still limit walking and time spent on my feet.

I apologize for not updating you all over the last four weeks.  I've been taking it from all sides, including my good friend Phil.  

Phil just recently moved to Denver for the sole reason to annoy me with the massive amount of regular weekend snowboarding he now does.  

This past weekend, Phil took a short drive up to Breckenridge on a mission to bust a widely held belief that there was no way I could possibly have been snowboarding at 40MPH when I hit the tree.  I thought that was awesome.

Without further delay, here is his write-up of his attempt to bust the myth!

MythBusters edition: Snowboarder vs. Collision Speed

If you have ever met Tony you know a few things about him:
  1. He never plays practical jokes on anyone.
  2. He never bets anyone to do pretty much anything
  3. He never over-exaggerates
Point three is what caused this analysis to be completed.  Tony's blog states that he ran into a tree at 40-45mph.  I have been skeptical of this number for awhile as I have hit a top speed of 53mph on my bicycle and that was pretty scary.  Since I have had no way to determine speed while snowboarding, 40mph seemed very fast.  I know pro downhill skiers hit 80mph and average 30 – 40mph, but that is on some steep terrain.  Furthermore, if you analyze the actual spot of the collision with the tree it is right off Lower American, a green (easy run).  

The Test:
Take a similar route as Tony and wear a GPS unit to determine speed.   

I spoke with Tony the night before completing the test to determine his actual route and possible variables in the setup.


Tony and I are built nearly the same as far as height.  Tony does weigh a bit more than I do, so that would also increase his speed [Editor's note: I weigh 200lbs now, jerk].  Tony's snowboard is 7cm longer than mine, which generally equates to a obtaining and holding higher speeds.

Height Weight Board Length Hair Eyes Riding Ability
Tony 6'4” 220lbs 165cm wide Brown Blue Treetastic
Phil 6'3” 200lbs 158cm wide Brown Brown Super Awesome


Tony started at the top near the Mercury lift then took American (blue\black diamond) to Lower American (A green) on route to clobber a tree.  My route was a bit different due to American being closed due to a lack of snow.  I followed nearly the same path as I took Sundown (blue) to Lower American (green).  The section actually containing the tree was also closed, so I had to detour around a section of trees.

Note:  Tony took American to Lower American before his accident.  How much more patriotic can you get?

Here is a map so you can compare our routes:

Since our routes are nearly the same I do not consider this is be much of a factor in the test.   Both runs are very similar, with American being a little bit steeper.  Sundown and American are very steep for the first part of the run dropping 40 vertical feet in about a quarter mile.  The runs both level out around 500 yards before connecting with the very flat Lower American.  Tony would have entered Lower American earlier than I did, so his speed would have started to bleed off a bit sooner that mine.  I believe this detail levels the playing field and negates any extra speed he would have had.  The slight detour near I had to take around the tree is nearly the same grade as the route to the tree.  Again, a slight difference, but it should not affect the results much.

Snow Conditions\Time of Day\Temperature:
The test was completed at 12 noon on ski runs consisting of groomed packed powder.  The temperature was in the high 30's\low 40's.

Editor's note: my crash run took place a little after 9:30AM with groomed packed powder.  The temperature was a bit colder -- low 30's.

Riding style: “You better go as fast as you can because that's how I do it.” -Tony, Dec 2011

I go fairly fast but I generally take it a little bit easy.  After riding with my GPS my average speed when cruising around is between 20 and 25mph.  I really had to step it up to meet the speed and agility of Tony.

Here is some interesting data from a few leisurely runs at Breck:

The Test:
On both runs I started collecting GPS data near the top of the run and stopped collected at the Mercury lift.  The ski runs were not too busy so it was easy to cruise on both runs.  I tried to straight shoot both runs as much as possible.  To maintain stability I did have to edge somewhat, but did so in a manner as to not lose speed.  I also took corners this way to ensure the most amount of speed was kept.  I tucked a bit at high speeds so I was more aerodynamic and also 'pumped' the snowboard on rollers to maintain speed.

Two different test runs were completed, both with very similar results.

Garmin's site is terrible for analytics, so I imported the GPS data into map my ride.

First Test:
http://www.mapmyride.com/workout/82299108 (Click on splits and graphs)

Second Test:
http://www.mapmyride.com/workout/82296678  (Click on splits and graphs)

The actual collision would have occurred between two data points:

Based on the graphs it is easy to see how fast speed starts to bleed off as you continue on Lower American.

The other test I completed had my speed was about 1 mph faster, so between 34 and 35.75.

The Results:

My estimated speed at the point of collision:  32 – 36 mph.

Based on the data it is possible that Tony was going 40 mph when he hit the tree.  This is due to the longer board length and because he is quite an all-American badass!

Speed Likelihood
30 Too Slow!
35 For Sure
40 Probable
45 Unlikely

Editor's note to all of my friends that doubted me: I told you so.

Thursday, November 24, 2011

Physical Therapy: Round Three

In the last two years I've had to rehabilitate my ankle twice.  Each round of physical therapy was four months.  With eight months of rehab under my belt, I thought I could handle round three myself.  I've seen all of the manipulations of the joints, the painful tendon stretches, and the strengthening exercises.

Turns out I don't know what I'm doing.  I start round three next week at CORE Physical Therapy.

The joints in my foot need a lot of work.  I'm not pushing myself hard enough on my own.  My foot is still very stiff and painful from reversing the contracture caused by being locked up for twelve weeks in an external fixator.  The contracture is clearly visible when compared to the much larger left foot.

The nerve damage in the ankle keeps the skin hotter than normal, quite red, and triggers the sweat glands to overreact.  While unlikely at this point, it's still possible to develop complex regional pain syndrome.  The neuropathy has died down significantly and feeling is slowly coming back.  All good signs.

June 2010 Ankle

November 2011 Ankle

The ankle is still feeling good, but it's important to loosen up the joints in the foot to ease the pressure on the ankle joint.  

The worst pain I have is when my blood pressure spikes -- something I've experienced regularly during the two rehab phases since the accident.  The pain from the inflammation in the foot is at its worst in the morning.  Ice and Celebrex are your friends.

The holes have almost completely healed.  A few days ago I had this sweet crater in one of my pin sites.  This thing was big enough to have its own gift shop at the bottom.  Fortunately, it has healed up since this picture was taken.

Hope everyone has a great Thanksgiving!  Since the accident I've had quite a lot to be thankful for -- not dying after snowboarding into a tree probably makes the all-time top ten list.

Sunday, November 20, 2011

Snowboarder vs. Motivation

After my third surgery last year, I worked out every day with one goal in mind: to snowboard one more time.  But as the ankle pain grew each day, it became increasingly difficult to walk to the gym.  Eventually I realized snowboarding was further away than I had hoped.

I stopped working out.

It was either the ankle pain or the knowledge that getting back to the slopes would be more difficult than I had imagined that killed my motivation.

Not this year.

One year later, I'm back in the same spot.  I'm back in the gym regularly.  I'm still motivated by the idea of being back on my board and dominating the slopes.  But I've also learned my lesson from last year.  Snowboarding is not my only goal (Dr. Jeng told me Friday to refrain from all high impact activities, including snowboarding, for one year).

Instead, my primary goal is to get down to and stay at about 190 to 180 lbs.  I'm 6'3" and at 200 lbs now, so this isn't asking much.  But the difference of 10 to 20 lbs will help manage my ankle pain.

With all of that said, I still dream about snowboarding.

I know.  There were also a bunch of skiers in this film.  If I can't maintain the dorsiflexion I need to snowboard, I've considered -- only briefly -- converting.  But that's a decision I can put off for at least a year.

Yesterday was the most active I've been on the ankle without crutches.  It's difficult to tell if I'm having ankle pain because the cuniforms, navicular, cuboid bones, along with the subtalar joint, are all experiencing wake-up pains -- and those are all near my ankle joint.

Here's what I've been doing every day to rehab the foot and ankle.

A half foam roll can be used to work on dorsiflexion and plantar flexion.  You can also turn it over and use it to roll your ankle side to side.  These things are cheap and worth it.

A wobble board is great for loosening up the ankle.  It allows you to move the joint in all directions.  I do three sets of 20 rolls in each direction every day.

A tennis ball is the cheapest and best thing you can get to rehab your foot.  You can use it to stretch the toes and the tendons under the foot.  If you have neuropathy, rolling your bare foot on the tennis ball helps.  It does a great job of desensitizing the nerve endings in the skin.

One more video.  This one's not motivational.  It's just dumb.

Friday, November 18, 2011

New X-Rays

The ankle feels great!  I'm off the crutches and on a cane now.  I don't have any pain in the joint (yet).  I'm continuing to take 200mg of Celebrex a day, which probably helps.  

Today we had our post-op x-rays taken of the ankle.  Before we see the images, here's what the ankle looked like around this time last year.

X-Ray taken on 8 December 2010

Here are today's pictures.

 X-Rays taken on 18 November 2011 (Side View)

There is more space in the joint.  However, the ceiling of the tibia in the front of the ankle -- which is actually my pelvis from last year -- is collapsed into the joint.  The X-Rays couldn't tell us if there was any joint space in this area.  While I have no ankle pain now, this spot could end up becoming arthritic over time.

X-Rays taken on 18 November 2011 (Front Angled View) 

X-Rays taken on 18 November 2011 (Front View)

Another noticeable difference is the bone is not as bright as the X-Ray from last year.  This is because the bone is no longer sclerotic or as hard and dense.  The distraction allowed the bones to develop osteopenia.  While this is bad when it occurs on its own, it's actually very good for arthritic joints.  Walking on soft bone is much easier on the joint than hard bone.

Also -- you should check out the comments from my last post.  Two fellow arthritis sufferers, Carlos and Paul, discovered that they were seeing doctors from the same practice.  Small world!

Paul recently had a similar distraction procedure performed on his knee (more awesomely gory pictures located here).

Carlos is considering ankle distraction and has found several other very promising research papers.
Thanks for sharing the papers!  It reminds me that I need to finish my post on recent ankle arthritis research.  I'll make sure to read these papers and incorporate the research in the write-up.

Finally, here are the flouroscopic images taken during the November 3rd surgery.  You can see that there appears to be much more joint space than what we saw today.  I suspect it's due to the fact that I hadn't started bearing weight.

Monday, November 14, 2011

Leg Holes

The leg is looking good.  Here you can see the 11 day old holes are healing up nicely.

This got me wondering: how many holes, incisions, and pins/screws have I had since my accident?  Time to add it up.

Surgery 1 on February 13th, 2010

Three external pins.

One plate.  Eight internal screws.  Seventeen staples.

One incision.

Surgery 2 on March 1st, 2010

One plate.  Eleven internal screws.  Twenty staples.

One incision.  Two holes for two internal screws in the medial malleolus.

Another hole due to infection in the top incision.

Surgery 3 on August 16th, 2010

Eight external pins.

Three new incisions.  Fourteen staples.

Surgery 4 on August 15th, 2011

Eight external pins (nine if you count the temporary pin to find my ankle axis).

Two arthroscopic holes.  Three tendo-lengthening holes.

Grand Totals
  • 2 plates have come and gone
  • 5 incisions
  • 8 holes from screws, arthroscopy, or tendo-lengthening
  • 19 internal screws (4 broken screws left)
  • 19 external pins
  • 34 holes from external pin sites
  • 37 staples
  • 39 holes drilled in my bone
  • 44 holes in my skin and bone if you add the external pin site holes

Sunday, November 13, 2011

Snowboarder vs. Neuropathy

The leg has healed enough to finally take my first shower without my right leg hanging out of the tub since August 15th.  While I was pumped to finally get this leg washed, there were some unfortunate consequences.


When I had my accident, my tibial nerve was severely damaged.  I lost all of the feeling in my toes, the bottom of my foot, and the medial side of my ankle.  After about eight months, the feeling returned.  But in the first few weeks of my accident, the neuropathy was terrible.  It felt like an electric shock in the toes and the bottom of my foot would feel like it was on fire.

Dr. Jeng warned me that distraction arthroplasty could re-injure the nerve.  It did -- I lost feeling in my heel and some parts of the bottom of my foot.

Feeling has come back, but it's still partially numb.  I suspect the shower removed a ton of dead skin and exposed some sensitive new skin on the bottom of my foot.  As the nerves heal, sensations like a breeze or touch register as pain.  It's awesome.  And I imagine it's a million times worse than this when you get an amputation.

There are a number of ways to treat neuropathy, but from what I understand, most of the treatments don't stop the pain.

I think our best option is to desensitize the skin on the foot using things like capsaicin and a tennis ball.  There's not much else you can do but grin and bear it.

Thursday, November 10, 2011

Physical Therapy: Round Three

One week later, how is the pain?

Before my surgery, I tried wearing my boot to see if it would help my arthritis.  At the time, it was extremely painful to get in the boot, extremely painful to wear it, and even more painful when I got out of the boot.

Since last Thursday, I have not experienced pain like that, which is great.  I don't feel or hear grinding noises (yet) from my ankle.  These are all good signs.

Unfortunately, having undergone this type of recovery and physical therapy twice before in the last two years does not make the third time any easier.  It definitely hurts.  Tendons, ligaments, everything has atrophied, contracted, and stiffened up.  However, reading what I was going through this time last year helps put things into perspective.

So far, I don't think I've felt any arthritic pain.  I'm taking Celebrex daily, which makes it easier to cope with the process of waking up my foot and ankle.

I have, however, felt some spots in my ankle, particularly on the anterior lateral side, that might end up becoming arthritic sites.  This is the area of my ankle I had the most pain before the surgery.  Dr. Jeng specifically removed bone spurs in that area of my ankle to address it.

I'm still holding out judgement until after I finish physical therapy.  We see Dr. Jeng next Friday to get x-rays.

Here's what my ankle looked like in December 2010, a few weeks into physical therapy.  You can see that there isn't much joint space left.  I'm hoping we see some improved joint space next week.  The flouroscopic images from last week's surgery looked promising -- but I'm afraid I was too optimistic (and drugged) when I created the "enhanced" image to help show the new space.

I'll keep you guys updated.  This is the part of the recovery that blows.

A friend of mine complained that there weren't enough gross pictures on my blog.

My leg has not been washed since August 15th, 2011.  Take a big whiff.  Be careful, though.  Even over the Internet, the stench can make you faint.

Sunday, November 6, 2011

Ankle Range of Motion in One Year

Dr. Jeng, if you're reading this blog post, don't get mad at me.  My dressing was making it difficult to wear my boot comfortably, so tonight I decided to change it tonight.

I took advantage of the opportunity to capture my current ankle flexibility and compare it against what it was a year ago -- a few days after getting out of my second external fixator.

November 6th, 2011

November 15th, 2010

It looks like in about one year, I've gained a little bit more range of motion.

Also, speaking of Groundhog Day, both of these videos, taken one year apart, have an NFL football game going on in the background.

Saturday, November 5, 2011

Finding New Uses for an External Fixator


Leg stool to elevate the leg.

Someone suggested I turn my ex-fix into a lamp.  I'm not sure my wife would like that.

Actually, I'm sure.

I had forgotten how much this thing weighs.  It's about five pounds.

The ankle is feeling great.  I'm experiencing the normal soreness and stiffness pains that twelve weeks of immobility will inevitably cause.  I've been using a half-foam roll and a wobble board to help me work out the stiffness while I wait for the wounds to heal.  Once they heal, I can start up physical therapy.

When I'm up and moving around at work, I'm back in a boot to provide stability.

While we're excited to see how much joint space we've acquired with distraction arthroplasty, I'm holding out judgement for about twelve more weeks.  The articular surface of my tibia is like a meat tenderizer.  Walking and moving the ankle will likely wear down the new tissue we've grown -- it's only a matter of time.

But that's the key question -- how much time have we bought ourselves before symptoms show up again?  The research shows about five years, but the procedure is still relatively new.  As a result, data on long-term outcomes is not readily available.

All things considered, it's amazing to see how far we've come.

From the initial injury above, to this, roughly two years later:

Thursday, November 3, 2011

Surgery Number Five

Mom.  Before you watch this video, maybe you should get Dad in the room to keep you calm.  The beeping noises you hear are all normal.  I'm safe and everything went as planned.

Here's the 22 minute video of this morning's operation.  I apologize for the quality, but my camera only allows me to capture approximately 10 minutes of HD video.  While this video is not as exciting as last year's cowboy ex-fix removal video, I think this video is more interesting and realistic for other patients undergoing a similar procedure.

Most people should be asleep for this procedure, particularly if the half screws are removed by hand instead of a drill from your surgeon's garage.

I had a local nerve block for this procedure, but it was not as intense as the August block.  When I woke up, I could feel my foot and leg.  As the block continues to wear off since this morning, I'm starting to feel more pain in the ankle joint -- particularly the posterior medial side of the joint.

I'd encourage you to continue taking Oxycontin and Oxycodone for a few days after this procedure, but plan on switching over to something like Celebrex soon.  I intend on easing off of both Oxycontin and Oxycodone this weekend, using Valium to help deal with the withdraw symptoms associated with discontinued use of these drugs.

Back to the video -- you probably noticed my awesome operating room nurse struck a pose after cleaning my pin sites in the beginning.  Another interesting moment was seeing how securely the two half screws were embedded in my tibia.  Particularly the distal screw -- Dr. Jeng had to bring in some elbow grease to get that one going.

Now on to some pictures taken before the procedure.

As you can see, I stuck with the plan to wear my sweet silver breakaways.

This is, hopefully, the last time you'll see an external fixator on my right leg.

The proximal pin site on the lateral side was continuing to leak normal edema fluid.  This is not a sign of infection.

The second-most proximal pin site had scabbed up since yesterday, looking much better.

The lateral pin sites in my fore foot were leaking fluid yesterday, but today they seemed fine.

So, after twelve weeks of ankle distraction, what were the results?  Here's where we started -- pay attention to the lack of space in my ankle joint.

There's no joint space here in this X-Ray taken in June 2011.  Now look at the flouroscopy images taken during today's surgery.

What's this I see?  I have joint space!!!!!!  Hard to tell?  Take a look at this enhanced image.

I was blown away when I saw how much joint space I now have.  Keep in mind that I have not been weight bearing on the new joint -- this is still only a few hours old -- but compare this joint space to the absolute lack of joint space I had in the June X-Ray above.  In June, my ankle was in a bone-on-bone contact situation, making the subchondral bone at the surfaces of the tibia and talus too dense.  When the bone becomes dense, it does not readily absorb the impact shock of walking as less dense bone.  Moreover, as joint space narrows, the synovial lining around the joint becomes inflamed and painful -- this is called synovitis.  It hurts.

During the first weeks of this procedure, especially after seeing the arthroscopic images, my hopes were not high.  Neither were Dr. Jeng's.  He managed our expectations and let us know that my ankle was in terrible shape.  There wasn't much cartilage to work with.

But now my hopes are a bit higher.  In one of the research papers I read last month (I'm still working on that post!), it's not just new cartilage growth and repair that helps increase the joint space after ankle distraction arthroplasty.  In fact, it is very challenging to regrow cartilage.  What we're finding out is other tissues grow in the joint space and act like cartilage.  Here's a very interesting quote from the 2002 paper, "Joint distraction as an alternative for the treatment of osteoarthritis:"
We have to keep in mind, however, that the observed clinical benefit might not be dependent on cartilage repair, bony changes, and cartilage–bone interactions alone, but may have many different origins.  For example, stretching the nerve endings during treatment, or a diminished synovial inflammation after treatmentmay relieve pain.  Also, the formation of fibrous tissue could explain the increase in joint space width.  Because the fibrous tissue is a soft tissue, it may change load transfer in the joint.  This could absorb stress during joint loading and by this mechanism diminish pain directly, or indirectly by way of secondary changes in subchondral sclerosis.
I think it's safe to say this research might be confirmed with my results so far.  I had essentially no cartilage left in my ankle, but after distraction for twelve weeks, I've got significant joint space widening.

We'll continue to monitor the pain and joint space as I start easing into walking again.  Stay tuned!