Preparing for Foot Surgery!
Edited by Stephen Pinney, MD
If you are about to have foot surgery it may be difficult to grasp all of the realities associated with undergoing foot surgery. Here is an attempt to give you general guidelines to help you on the road to a smooth recovery that is free from surprises.
Prior to surgery
Understand your operation!
It is critical that you be very clear on what surgery you are having; why you are having this surgery; what the expected recovery time will be; and what the potential surgical complications are.
As all operations differ, it is important that you ask specific questions about your surgery. Write down any questions you have. Ask your surgeon or his/or her surgical team to answer these questions. If you are not completely clear on one or more surgery-related questions, do not hesitate to say something like “Here is my understanding of what you are telling me… Is this correct?”
Proactively prepare for the recovery period
Try and think about all of the things you are likely to need in the recovery period. Some things to do:
- Stock up on supplies (food etc.) so you do not need to leave the house often.
- Enlist the help of your family and friends.
- Get some books and movies to occupy your time in the recovery period
- Driving (DMV) – Obtaining a Temporary Handicap Placard
- Practice walking with crutches
- Consider purchasing or renting a knee walker/knee roller
Prepare your home
Move objects that will make it difficult to move from one room to another. Consider moving your bed to the ground floor. Prepare your bathroom and shower area (shower stool, grab bars, etc.)
Create a Command Post
It may be a good idea to create a “command post” -a bed or sofa stocked with supplies that you can readily reach. Suggested supplies are:
- TV with remote control
- Hospital-type table that slides over the bed or couch may be helpful
- A foot elevation system of some kind (ex pillows)
- Easy access to ice or a cooling system
- Bed backrest
- Writing materials such as pen and paper (ex. to keep track of medications)
- Drinking supplies
- Metamucil or Colace as bowel activity is limited by pain medications
- Hand lotion
- Any handiwork that you might be interested in (don’t expect to have the mental ability to take up a new hobby)
Showering after foot surgery can be a challenge. It is important to shower in a manner that optimizes safety. Falls in the shower during the post-operative period are surprisingly common and can lead to damage to the surgical area or injury to a different area of the body.
When showering, you should sit on a shower stool. A shower stool that is made of plastic or wood will usually tolerate water from a shower. Commercially available shower stools or benches can be purchased and may have some advantages over a regular chair. A human assistant can be very helpful, especially with getting in and out of the shower.
It will be helpful to place grab bars in appropriate locations on the shower. Grab bars can be obtained at many hardware and bathroom supply stores.
It is usually necessary to use a waterproof container to cover your foot and lower leg when showering so as to avoid getting the cast or dressings wet. This can be achieved by placing a plastic garbage bag over your foot up to the level of the knee. Alternatively, you can purchase a commercially available “cast protector” which may be easier and more effective to use. If you do get a cast wet it may be necessary to change the whole cast, as getting the cast lining wet is similar to wearing a wet sock around. It is not at all good for the skin, or for wound healing.
Down Time: How long off work?
As part of your pre-surgery preparation you need to understand how long your “down time” will be. If you work, how long will you need to be off the job. This can vary greatly depending on the surgery –and whether your job is largely sedentary or whether it requires prolonged standing and walking. A relatively non-invasive surgery such as a small hardware removal for someone who has an entirely sedentary job may require minimal time off work. However, a major surgery in a patient who needs to be on his/her feet all day (ex. a nurse or a construction worker) may require six months or more off work. There are some surgeries that are likely to be “career ending” if a patient has a job that demands standing and walking all day. It is critical that each patient understand the time frame that their surgeon feels they will be off work. Be sure to ask your surgeon for a detailed review of what can be expected during the recovery period, although it is important to realize that recovery times can vary greatly between patients. Obtaining a note to give to an employer outlining how long you will be off work is a helpful starting point to discussing the recovery time that is to be expected. Clarify any questions that you have about your surgery and the expected recovery time before your surgery. No one wants any “surprises” in the post-surgery period.
Down Time: How long off Driving?
If you drive a car your ability to drive can be impacted profoundly or minimally depending on what foot is operated on and what type of care you have. The most important thing regarding your return to driving is SAFETY! A safe return to driving is much easier and quicker if you had minor surgery on your non-driving (left) foot, whereas it can take many months to return to safe driving if you underwent a major operation on your driving (right) foot. You should discuss the likely timeline for returning to driving with your surgeon -before your operation! In addition, if possible arrange for a Temporary Handicap placard during your recovery period. In most states, this requires your physician to complete a Temporary Disabled Parking Permit. Many surgeons will have these forms in their office. If they do not, you can usually download a form from your state’s Department of Motor Vehicle (DMV) website. You may be charged a small fee to have this form completed. Once completed, the form can be mailed to the DMV and it takes a few weeks to be processed. Alternatively, you can make an appointment or walk into any DMV office with the form and they will issue the placard. You should consider doing this prior to surgery, as standing in line with crutches while your leg is dangling down shortly after surgery can be problematic.
After surgery, you will have swelling in the foot, and pain. The swelling is related to the increased blood flow to the foot in response to the “surgical injury,” as well as the decreased capacity of blood to return to the heart due to fewer lower leg muscle contractions (which have the effect of increasing venous blood return). Swelling is often directly proportional to pain. The greatest swelling occurs in the first 3-4 days after surgery. After that, the swelling gradually diminishes. However, it often takes many months (or even a year for major surgery) for all of the swelling to resolve. The pain associated with swelling can vary widely. If it is not managed appropriately, it can be very uncomfortable and frustrating. Keeping the leg elevated, particularly in the days immediately after surgery, is the best strategy to minimize swelling.
Post-operative pain control
There are a number of ways that post-operative pain can be managed. You will likely need to use a combination of the following strategies:
Post-Operative Nerve blocks: Many anesthesiologist or surgeons will perform local (nerves around the operative site) or peripheral (nerves leading to the operative site) nerve blocks. This is similar to what the dentist does when fixing a cavity. It can leave your foot numb in the short term after surgery. However, it can be very helpful in the hours immediately after surgery and can really minimize the amount of pain medication that is required immediately after surgery. Depending on the type of “nerve block”, the local freezing may last from 3 hours to 15 hours (or longer)
Foot Elevation: Keeping your foot elevated 6-18 inches above your heart can be very helpful at minimizing swelling and therefore decreasing post-operative pain. The best way to elevate your foot in this way is to lie on a bed or sofa with one or two pillows under the foot.
Activity modification: It is critical to avoid activities that will require you to have your foot dangling down for any significant period of time in the early post-operative period. Therefore avoid shopping excursions or other activities where you will be standing for any length of time, in the first few weeks after surgery.
Ice: Ice placed in a plastic bag or a package of frozen vegetables can be very helpful at controlling post-operative pain. Ice should be applied for 10-15 minutes at a time and then removed for 10-15 minutes. Ice should NEVER be used when the foot is numb from a nerve block as this can easily lead to frostbite. A cast or a thick dressing may diminish the effect of the ice as less cooling will get to the operated area. Ice works in part by constricting the small blood vessels around the foot and ankle and thereby decreasing the blood flow to the area. There are commercially available ice pumps that can be helpful, but should again NEVER be used if the foot or ankle is numb.
Anti-inflammatory pain medication (NSAIDs): Anti-inflammatory medication (ex. Ibuprofen, Advil, Motrin, Aleve, Voltaren, etc.) can be a helpful additional means of managing post-operative foot pain. However, NSAIDs can have significant side effects such as stomach irritation, ulcers, bleeding; or kidney problems so not all patients (ex. many older patients) are good candidates for NSAIDs. In addition, there have been some laboratory studies that suggest that NSAIDs may have a negative effect on bone and ligament healing. Fortunately, this has not been determined to be a significant issue in most patients undergoing surgery.
Narcotic pain medication: Narcotic pain medication is often prescribed after surgery. It can be very helpful at managing pain but does have side effects. There are many different types of narcotic pain medication (ex. Vicoden, Percocet, Norco, Tylenol #3). Most are short-acting, lasting for 4-6 hours, and will therefore need to be taken regularly to achieve their effect. It is important that you take enough pain medication to stay ahead of severe pain. Side effects of pain medication can include: nausea and vomiting, confusion (or feeling “weird”), constipation, and the potential for addiction. The problem with narcotic addiction has become a profound issue in our society and many individuals with narcotic addictions started with pain medications that were prescribed after surgery -either their own operation or someone else who ended up not using all of their narcotic pain medication. Studies have shown that post-surgical patients experience addictive type symptoms (ex. withdrawal symptoms when they stop the narcotics) after only 48 hours of taking narcotics. Also, patients who are still taking narcotic medication regularly 12 weeks after surgery have a 50% chance of still being on the narcotics 5 years post-surgery. As a result, there has been a push to limit the use of narcotics to the initial period after surgery -or to eliminate their use in favor of other pain control strategies. One strategy to achieve this is for the surgeon to only prescribe a small number of pain pills (ex. one week supply) and require the patient to get a refill if they need more.
Multimodal Pain Management: Recently there has been increasing evidence demonstrating the effectiveness of a multimodal approach to post-operative pain. This essentially means using different pain control strategies, both pharmacological (narcotic and non-narcotic) and non-pharmacological (ex. ice, elevation, visualization and breathing techniques, etc) at the same time. The advantage of this approach is that each of these individual approaches to pain control works at a different point in the pain pathway, so by employing multiple strategies there is a cumulative effect and then need to strong narcotic pain medications is lessened or eliminated.
Work: Be prepared to spend much of the first one to four weeks lying in bed or on the sofa with your foot elevated. Your primary “work” during this time will be to facilitate foot healing. The first few days you will likely find it too painful to put any weight on any part of your foot, so you will need to be waited upon, or you will need to use crutches and/or a walker, or if your arms are weak a knee walker, wheelchair, or scooter. You should not return to work until you believe you can function at an acceptable level. This will depend on the type of surgery you had, as well as the type of job you have. Remember that when you are taking pain medications, your thinking ability may not be 100%. Consider avoiding work conversations and serious emails while you are on regular narcotic pain medications.
Edited June 16, 2019