Apr 21, 2015

The AFO and Toes, aka There's Nothing Cute about Curly Piggies

I was in the 7th grade of Junior High School (they call it Middle School now), when I first learned from Lydie Miller during a pajama party that I had funny-looking feet--teeny, tiny toes like my rather portly father and sharp bunions like my mother.

Tweens are more sophisticated today, with conversations about getting higher on E, listening to the "good kind" of rap, or deleting unwanted photos on Instagram. But 54 years ago, it was feet. It wasn't the first time that I said, "I have rotten genes."

Anyway, Lydie was right. After that bit about my feet, I never exposed my toes to strangers again. I always wore shoes, never sandals, to the pool, and covered my feet with a towel. On the beach, I dug my toes into the hot sand. I had my bunions straightened, but there was nothing I could do for the exceptionally short toes. That realization changed my being. I always stare at feet to evaluate them: better or uglier than mine. It's a slam dunk. "Better" always wins.

After the stroke, the only news that made me happy was I could only wear sneakers. My toes' secrets were safe forever.

I was fitted for an AFO (ankle/foot orthotic) somewhere around the middle of my 15-week stay in rehab. But somewhere after the 5th year post-stroke, I learned of a new problem with the AFO. My 2nd toe began to curl, so much so that it inhibited my walking at times.

It's not a new problem. Just new to me, and probably you, too.  

Dr. Stanley Beekman, a Cleveland-based DPM, did a flexor tenotomy (cutting the tendon of a metatarsal) on many patients wearing an AFO post-stroke, or anybody who suffered a brain injury of a different sort. 

He said in 2005 (the brackets are my interpretation], "Patients post-CVA do not have a normal [forward-walking] gait, and therefore do not need the digital flexors to [lift off] the ground at push off to off-load the metatarsals because there is no push off. This is why this procedure will work in this situation." This procedure, the flexor tenotomy, will work on hammertoes and other lower-digit problems, too.

In 2008, the Podiatry Institute said, "The simplified technique [flexor tenotomy] utilizes an 18-gauge needle to perform the surgery but does not require suturing and the patient may get the foot wet the next day. 

"This technique is performed in the office under a local digital block. After the digital block is performed and the toe prepped, the same needle used to draw up the local anesthetic to administer the digital block can be used for the surgery. An adhesive bandage is often the only dressing required postoperatively."

If you want to see a video of the procedure that takes about 30 minutes for 1 or 2 toes, watch this: https://www.youtube.com/watch?v=GHx8-GyHhcQ 

So I did it--flexor tenotomy--and I didn't see a thing, aka blood and gore. My foot was elevated to shoulder height and the 2nd toe had the tendon cut.

Just like the Podiatry Institute said, I was up and about in one hour. The pain: minimal. The result: it's too early to tell, but my toe is straighter than it was. And for me, I'm walking faster, and that's good enough for now.

Apr 11, 2015

WARNING: Three Things You Need to Know About Your AFO (Ankle/Foot Orthotic), aka People Fuck Up

A long time ago, in a land far, far away (I'm kidding--it was New Jersey), a man, called an orthotist, came to Absecon Manor, a nursing home where I was a patient, and huddled with the physical therapists with no input from me. I wanted to know about the options for materials for the brace, the cost, the right to come back for fittings. But they huddled without me. 

He fitted me for a brace, wrapping plaster on  my socked leg that acted as the mold. He produced what is known universally as an AFO (pictured right).

I hated the AFO. It was cumbersome, and the man told me, in no uncertain and threatening terms, that I could go nowhere without it. I had to wear a high sock, even in the blazing heat of summer, to cover the plastic of the brace which would irritate my skin if it got stuck to it. At night, I'd take it off, where many times the AFO would go with me for an urgent bathroom trip. 

Brace on when I awoke, brace off when I wanted to read stretched out on the sofa, brace on when I wanted a drink from the kitchen, brace off when I wanted to take an hour nap, brace on when I wanted lunch, brace off when I wanted to do my sitting-down exercises, brace on when it was night to close the blinds, brace off.... You do have the pattern, don't you?

Medicare will pay for an AFO every 5 years, and I had the brace for 6 years, so when I moved to Pennsylvania, I found out the AFO was made incorrectly. But I'm getting ahead of myself. Here's my story: 

There are 3 places where I could have the brace made in Pittsburgh. I went to the first, but the orthotist contradicted himself twice. So I lost confidence in him for what I thought was unadulterated bullshit. 

I went to the second place, but the orthotist didn't remember that she took pictures of the old brace twice to remind herself where the strap had to go, she didn't remember an appointment I made with her, and she said there would be a charge when there wasn't any. The same deal. No confidence. 

There was only one place left. I met the orthotist--I'll call him Bill--and he didn't like all the questions I asked, and he would rather that I be stupid, just barely tolerating the questions. And I just barely saved the best place for last.

Bill socked my foot and put the plaster over to create a mold. I came back in a week to receive the finished AFO.

"It hurts in my ankle and there's pain around the calf," I said.

"Try it and call us back if there's any problems," Bill replied.

"Um, I already told you. There's pain in my ankle and calf."

So he adjusted my AFO with some kind of melting-plastic thing and tried it again.

"That's all I can do," Bill said, preferring the people who went in there were uncomplaining and settled on whatever they dished out. 

I left because I had 90 days to complain. I read the fine print.

I called the next morning to request another appointment, and the receptionist said there was nothing available until next week. 

"Look again. My old brace has fractures, and it's only a matter of time when I will be bedridden without the brace," I whined. The old brace did have fractures, but bedridden? I may have exaggerated a teensy bit, but as my father once said, "The squeaky wheel gets the oil." So the receptionist found a spot that afternoon.

But this time, the manager--I'll refer to him as Dave who is an orthotist as well--was there, filled with so much more knowledge than Bill and offering to recast my leg for yet another brace.

I have been there 4 times so far and here's what Dave said, 3 things about the AFO that I think you should know:

1. The AFO must come 1" to 1-1/2" below the head of the fibula. You probably won't know what I'm talking about, but the orthotist will. Dave said the 6-year-old brace was too tall and Bill's brace was too short. Maybe that's why Bill's brace caused me pain, impinging on a nerve. I was impressed with Dave's honesty. He had my interests, instead of the company's, at heart. 

2. Dave also told me that the best material for the AFO is co-polymer, rather than the polypropylene which is a generic name for thousands of compounds used by thousands of vendors. The co-polymer is more rigid and 1/16 of an inch thicker, but it isn't subject to the fractures around the joints--the places where nut and screws go on the AFO--like the polypropylene.

3. The AFO, like the original, 6-year-old one, was free of charge. That news only cheered me up because I needed it. It wasn't a "hurrah" moment and I already knew that Medicare covers the AFO every 5 years.

But there was a chink in the armor, if you will. I'm going back, one more time--at least. My physical therapist saw my new brace and told me to tell Dave that my foot is externally rotated. The brace is supposed to re-mediate that problem, she said. Dave told me that my foot is internally rotated, coming from my hip. There's nothing more he could do.

So they're going to have a conversation in a few days--two experts who both know what they're talking about. Hoo-boy. I'd love to be a fly on the wall for that exchange. I'll let you know in a future post who won. 

Bottom line: I have to wear this brace 18 hours a day and it can't be a C+ situation. The AFO needs an A+. I won't settle for anything less. You shouldn't either.