July 2013

Patient Perspective: Bunionectomy recovery is more than just healing

9_FA_patient_perspBy Karen Bakar

I can’t recall exactly when the bunion on my left foot started causing discomfort, but it was probably when I was about 40. I waited some time to get a referral to a podiatrist, and when I finally saw one, life with two kids and a full-time job stalled my pursuit of treatment for another three and half years.

The podiatrist diagnosed moderate hallux valgus–not the worst case scenario, but I was definitely a good candidate for surgery. He explained that, while the procedure would correct the problem, the decision to go that route was ultimately up to me, based on my willingness to tolerate the discomfort of doing nothing.

I knew people who had gone through the procedure, and their accounts of severe pain in the immediate aftermath, as well as weeks of inconvenience scared me off, so I opted to first try managing my pain with new footwear. My shoe budget expanded, and I found salvation in several pairs of clogs and other more sensible, but expensive, styles. Even so, eventually the moderate discomfort I was experiencing turned to excruciating pain that often kept me awake at night and disrupted my workouts.

On my next visit to the podiatrist, in June 2012, I was intent on scheduling a date for surgery. Anticipating about a month of major life disruption, I targeted January 2013 for the procedure, when the craziness of Thanksgiving and Christmas would be behind me, work would be reasonably slow, and family and travel commitments were minimal.


Healing the bone

Figure 1. The soft boot worn immediately after surgery.

Figure 1. The soft boot worn immediately after surgery.

On January 9, my podiatrist performed a bunionectomy with distal osteotomy. He prepared me well for the surgery and reviewed milestones and expectations for the first two months. As he described it, this period is about healing the bone. The progression is predictable–from five days with absolutely no pressure on the foot, to the resumption of modified activities in six to eight weeks. Nearly five months postsurgery, I’ve learned that “healing the bone” is only one part of the full recovery.

The initial pain was not as severe as I had expected based on my friends’ accounts, and I never felt the need to fill the Vicodin prescription the nurses gave me. I think my podiatrist’s advice was sound–to let the local anesthetic wear off, and then evaluate the pain level. In my case, over-the-counter relief was sufficient.

I found that during the first few critical days it was important to have lined up help. Friends had arranged meal deliveries every night for the first week, a lifesaver given my inability to get out of bed without crutches. Having a husband who works at home and kids old enough to be somewhat self-sufficient certainly didn’t hurt. The relatively manageable level of pain continued to surprise me, though knowing how fragile my foot was, I was petrified that someone would bump it or that I’d accidentally step on it. One wrong move could send the pain meter off the charts and me back to the operating room!

My biggest concern was sleeping, when things beyond my control could come into play–the dog could jump on the bed and onto my foot, I could get up in the middle of the night and forget I had just had foot surgery (thankfully, that never happened), or I could make involuntary movements while sleeping that might jostle my foot. I wore the soft boot the podiatrist gave me for moderate protection, and had to sleep on my back for several weeks with my foot elevated and outside the heavy covers. It didn’t make for a great night’s sleep, but it worked well enough.

Getting back into a routine

After four weeks, I returned to work, mainly sitting at a computer. I’m fortunate to have great health benefits, so I was able to maximize disability leave. I arranged parking inside my building during the first two weeks of my return, and, with swelling still an issue, I brought a pillow to prop up my foot. I also had my podiatrist provide me with a medical certificate so I could apply for a disabled parking placard from the State of California.

The walking boot I started using five days postsurgery was unattractive and clunky, but did the job and sure beat crutches. Because it didn’t go far past my ankle, it allowed me to walk with a somewhat normal gait. Wearing a flat but elevated shoe on the other foot helped keep my hips aligned and minimized the limp. I found that Dansko clogs were almost the perfect height (1.5-in heel) to match the boot’s elevation.

Once out of the walking boot, a little less than six weeks after surgery, it was time to venture into real footwear. (Even today, more than six months postsurgery, shoe selection is a bit of trial and error and one of the more unexpected frustrations of my recovery.) The podiatrist suggested soft tennis shoes as a first step, but I found the laces were too constricting, and I couldn’t fit the sneaker onto my foot. The best postsurgery shoes, for me, were shearling Ugg boots. Assuming the boot is not too snug to begin with, there’s generally enough room to accommodate some swelling. The soft, flexible material and internal padding were so comfortable I almost forgot I had just had foot surgery.

Figure 2. Examples of shoes the author still was unable to wear five months after surgery because they cut across the incision area.

Figure 2. Examples of shoes the author still was unable to wear five months after surgery because they cut across the incision area.

By two months, I still hadn’t started working out even though my podiatrist said I could begin exercising after four weeks. Exercise means different things to different people, so when doctors have that discussion with patients, it’s wise to be specific about the types of exercise the patient enjoys and what their goals and expectations are.

My particular routine involves aerobic classes, yoga, and dance. All of these require a high degree of toe flexibility, and are thus harder to resume than activities with little to no strain on the toe, such as swimming or riding a bike. I waited three months after the surgery to resume working out, and even then, began at a modified level and pace. It took a good four months to ramp up to my preferred routine. Five months after surgery, I’m enjoying these activities with a lot less pain than I had presurgery; however, I’m not yet pain-free, and I continue to notice the difference in flexibility between my two feet.

Bumps in the road

By the two-month mark, the danger of complications related to the bone healing had passed, and up to that point, my recovery was pretty much textbook.

Figure 3. The author’s active lifestyle requires a high degree of toe flexibility.

Figure 3. The author’s active lifestyle requires a high degree of toe flexibility.

Swelling and moderate pain continued to be issues, however, something I hadn’t expected at this stage of the game. I knew the recovery would be difficult, but I didn’t realize how prolonged it would be. Everything I had focused on up to this point was about healing the bone and keeping it safe. The milestones my doctor outlined so clearly were easy to define, and I understood exactly what I needed to do.

After the eight-week mark, though, as I was transitioning into normal activity levels, I realized my recovery would depend as much on me as it would on my doctor. The podiatrist had guided me successfully through the precarious first few weeks of healing, and while follow-up visits were still on the calendar, the homestretch to recovery–including the ability to do my normal workouts and wear halfway attractive shoes–would involve more time, effort, and some unexpected bumps in the road.

One day at work, two months after surgery, I noticed my foot had become unusually swollen and was turning a disturbing shade of purple. My calf started to throb unbearably with what could only be described as a warm sensation. I had developed a blood clot, and if a coworker hadn’t suggested the possibility, it never would have occurred to me. Sufficiently alarmed by my colleague’s observation, I did some amateur research and discovered that I had almost every symptom and risk factor one could have for deep vein thrombosis (DVT).

Blood clots: Rare but risky

Surgery is a general risk factor for DVT, but the condition is not common after a bunionectomy. Statistics about the risk of clotting after this procedure are hard to come by, and according to my hematologist, bunionectomy is not the type of high-risk procedure that typically causes clotting.

Figure 4. Physical therapy helped significantly improve forefoot range of motion in the operated foot.

Figure 4. Physical therapy helped significantly improve forefoot range of motion in the operated foot.

Nevertheless, my surgical history combined with the facts that I was taking oral contraceptives, had been on a recent flight, and had been relatively immobile for so long after the surgery, seemed to have created a perfect storm. It’s unlikely the surgery caused the blood clot, but I’m convinced it played a role.

Doctors performing bunionectomies might do well to warn patients, especially women on birth control, about the possibility of DVT, despite the low risk. I might have opted not to fly when I did. I might have been more conscious of staying mobile, elevating my foot more frequently, and staying better hydrated to minimize the risk of DVT. I certainly would have stopped taking oral contraceptives, the most significant risk factor.

Recovery after healing

Five months after surgery, I’m on track to what I hope and expect will be a full recovery. Even though my foot has technically been healed for months, it’s not 100% recovered. I still experience minor swelling around the incision, and that keeps me from wearing about a third of my shoes–the ones that have the least flexibility and that cut across the surgical site. “Thickness or puffiness” is how my podiatrist describes this swelling, and I usually notice it at the end of the day, especially with tighter-fitting shoes. He explained that the bunionectomy procedure itself results in trauma to the toe joint capsule and surrounding soft tissue. Compared with bones, soft tissue is slow to remodel, which is why full recovery extends beyond the initial healing.

Figure 5. The additional forefoot flexibility has helped the author get back to favorite activities like yoga.

Figure 5. The additional forefoot flexibility has helped the author get back to favorite activities like yoga.

Toe joint mobility wasn’t something my podiatrist and I discussed in great detail during those early appointments, but it is a helpful conversation to have, if not early on, at least after the first critical six to eight weeks have passed. In my last and final appointment with my podiatrist, he explained that by six months, the flexibility in my toe should be “good to very good,” and that by a year, things should finally “look and feel normal.”

In my case, a month of physical therapy to mobilize the joint capsule has helped me regain some of that lost flexibility. My podiatrist did not initially discuss therapy as part of the longer-term recovery strategy, but I requested the referral because I was afraid that, without it, my foot would forever be stiff and inflexible, an unwelcome scenario given my level of activity.

My podiatrist and I were impressed with the results. After four visits, supported by a handful of home exercises to force greater joint mobility and break up scar tissue, I’ve achieved measurable improvement. From the first therapy session to the last, the flexion of my toe increased from 10° to 30°, and the extension from 52° to 70°.

Would it be enough for a ballerina on pointe shoes? Probably not, but for me, it’s what I need to finally kick up my heels and do the things I’m used to doing.

Karen Bakar is a freelance writer in the San Francisco Bay Area.

52 Responses to Patient Perspective: Bunionectomy recovery is more than just healing

  1. Bonnie says:

    Hello survivors! Everyone’s input is so helpful. It’s 11/15/19. Had bunionectomy/hammer toe repair 10/1. Been in a non-weight bearing cast and in a transport chair. Hippyhoppy from transport chair to toilet and back–the worst! Dignity-gone! Have nearly forgotten what 5’6″ is like. Hard hard time. Tears and pain, but got to ibuprofen only in 3 weeks. The magic words I want to hear at the docs tomorrow after cast off and xray are “Time for a boot walker.” Yes pleeze! So future readers–follow directions, do everything carefully, have friends/family/church fix meals for you, or Safeway delivery. HEAL! Rest! Foot up a lot! Elevate! Be patient. Be the turtle not the hare. I’m in the past, but you are in my future prayers. You’ll get through this!

  2. Simona says:

    I’ve had a bunionectomy and hammer toe repair (right foot) three weeks ago. Looking at all the postings and seeing all related YouTube videos made it all so clear that everybody’s experience is different and also all surgeons have different ideas and techniques. I marvel when I read that some of you are/were able to walk days or just a couple of weeks after surgery. As for me, I was told « no weight bearing at all ». Although the surgeon recommended fusion of my big toe, I didn’t go for that since I heard that that would render my foot stiff and unable to wear anything other than perfectly flat shoes. My doctor put a temporary pin through the second toe (formerly hammer toe) but no permanent hardware anywhere. At 2 weeks I had the stitches removed and that was quite painful, as it happened and some 24-36 hours after. In fact, the pain was quite severe. I was told that if I thought I could walk on my heel, I could, but I can’t. For the first two weeks I wore an Aircast, a rigid boot. Now I am in a rigid sole neoprene sandal. It says Procare on it. I keep it on most of the time. Underneath, I have an ace bandage and under that, layers of gauze bandage covering steri strips. I am in bed the majority of time, with my foot up. I sleep like that too. Quite uncomfortable. Since the surgery, I haven’t been able to sleep more than a few hours a night. Also, showering is a huge problem because the foot has to be isolated, covered and secured in a plastic bag and my foot outside of the tub. I sit on a bench in the tub while showering. I was told that I will only be allowed to get my foot wet 3 days after they take the pin out and that will be 6 weeks after surgery. I cannot wait.

    THE MOST IMPORTANT THING FOR ME is the mobility aspect. I was given both crutches and a walker and told and shown how to hop. But hopping is very tiring. The walker was marginally better for me because I felt more secure. I hopped to and from the bathroom for 8 days and I was losing my mind. I ordered a knee scooter but it was impracticable since you need more space to turn and so, I had to return it. The best solution that I hit upon is to use a ROLLING 360 degrees OFFICE CHAIR. This works quite nicely. I wonder why nobody mentions this. It is simple and effective and I already had the chair. Still, it would be nice to walk. And I definitely will ask the doctor to give me a prescription for physical therapy. Good luck to everyone!

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