Two Foot Surgeries, Gut Health and the Effect on Inflammation
Two significant foot surgeries (lapidus procedure on both feet) that each required 3 months of recovery consumed 2018. The decision to have surgery was difficult because I wanted to be sure my pain was not simply a part of psoriatic arthritis. I did significant testing in the years leading up to my psoriatic arthritis diagnosis so I was confident that I had a structural defect in my feet. This was not cosmetic or due to me wearing high heals although most women’s shoes are too narrow for their feet. My first & second metatarsal bones were at about a 17-degree angle when they are supposed to be closer to a 7-degree angle. The spread was only going to get worse over time so I had to tackle this before I got too old to manage the recovery. The surgeries restructured the bones of my feet in such a way that my gait and posture will change, and it will take at least a year after the second surgery (18 months total) to grasp the final effects. I know some of my pain will not improve, but it is still too early to draw conclusions.
I am grateful that I stumbled through getting the psoriatic arthritis diagnosis & learning about the needed diet changes before these surgeries. I am probably in the best health of my life even though I now deal with psoriatic arthritis pain daily. Because of my diet changes and elimination protocols over the last 2 years, my gut is fairly healthy, my body is in a good place to heal and grow bones. I am amazed at how well my muscle strength has held up and is returning as I rebuild my calf muscles by swimming daily and doing minimal Pilates.
The healing process was very slow, 6 weeks in a cast and 6 weeks in a boot-gradually adding weight while in the boot. My first foot was swollen and warm to the touch the entire 12 weeks (the second is still swollen & warm). Some days I go too far and find myself exhausted. On those days, I listen to my body, lay down and put my foot in the air. The work I was doing on my gut was going on before my surgery, but it was during my recovery that I began to write it down and ultimately decide to share what I’ve learned via this blog.
Gut health before surgery
I strongly recommend tackling your gut health prior to tackling any major surgery, especially if you have any type of autoimmune disorder. In my case, that work took about 2-3 years. If you already know you have a gut microbiome issue, then you’ll get there quicker. My gut was not 100% healthy when I tackled my first surgery, but I didn’t realize it at the time.
About a year before my first surgery I made dietary changes by tackling an elimination protocol that was roughly based on both the Whole 30 (link when write review) and an Autoimmune Paleo(link when write review) plan. After the elimination phase, I continued to avoid sugar and starch. That made a tremendous impact on the way I felt, and I lost about 8 pounds as a result. But when I look back, I realize I had episodes of diarrhea when I slipped up & had too much wine or ate a dessert 3 days in a row while on vacation.
Gut health during surgery year
Immediately following the first surgery, I followed a clean diet for about 3-4 weeks. No sugar, starch, alcohol (those are my big ones). I didn’t worry too much about incidental soy, corn, legumes, etc. as I don’t eat much of that sort of stuff anyway and people were bringing us meals, so I couldn’t be too picky! But I also deliberately added things like bone broth and fermented foods.
While recovering from my first foot surgery I read about 5 books that linked gut health to autoimmune disease in one way or another. The one that seemed to offer the most clear-cut options that I had not yet tried was called the Gut Health Protocol. This book is a wealth of information but could benefit from some organization. It is like a menu of possibilities. I selected the supplements I thought were best for my symptoms, made a plan & implemented a protocol while recovering from my first surgery. I added one supplement per week, kept a detailed log of my symptoms, maintained the protocol for about a month, and then removed one supplement per week. I also practiced fasting one day/week during this time. All of the above had a profound impact on my gut and I believe reset my gut microbiome.
Functional Medicine or Integrated Functional Medicine
I considered seeing a digestive or functional medicine practitioner during this time. (future link to a post on my research about the different types of doctors). My rheumatologist helped me realize that I had made significant progress on my own and should continue with my own experimentation. Functional Medicine testing is out-of-this-world expensive and insurance doesn’t cover it. Some practitioners required that I do their entire “program”, but I didn’t need their lessons on diet & recipes as I was already doing all that. I considered getting some of the tests run on my own, but that research led to even more disturbing conclusions about the testing. Many of the tests we run are testing blood levels of various nutrients/allergens, which are not exactly relevant to gut health. Some tests use the saliva levels, but timing is critical to the results you get. It was all very complicated, very expensive, and not regulated or standardized. I had already achieved significant results through the gut protocol and didn’t think I would learn enough to justify the thousands of dollars of cost. However, I am not opposed to going down this path in the future so I’m keeping all my notes!
Pain Medicine and the Gut
I did my best to avoid pain medications, but this was major surgery. The nerve block lasted for 24-48 hours. During the first surgery, everyone cautioned me to not get behind the pain, so I took hydrocodone frequently (~every 4 hours). But no one had told me about the constipation issue so by day 4 I was in incredible pain, taking stool softeners, and that first BM was the worst experience of my life. Childbirth was easier. After that I only took Acetaminophen. With the 2nd surgery, I was better prepared, so I started stool softeners as soon as I started the opioids. I asked for Tramadol because I was told it is easier on the bowels, but I also found it to be a little less effective. So, I would alternate Tramadol and Hydrocodone. They also prescribed gabapentin with the 2nd surgery. I took it dutifully but began to suspect it was causing muscle spasms during the night so stopped it (with doctor approval). I took opioids for a longer period with the 2nd surgery but I also spaced them out more and only took them when I felt like I really needed the pain relief, usually later in the day. It looks like I was only taking 1 opioid a day after about 3 days and then I skipped a few days, stopping completely after 7 days. While I was on the opioids I would supplement with Ibuprofen, but once I stopped the Hydrocodone I started taking Acetaminophen instead of Ibuprofen. The opioids definitely slowed the digestive process and I’m sure my gut microbiome was extremely confused. It is very important to eat well while on these medications, take stool softeners, and if needed probiotics.
Does Surgery Disrupt the Autoimmune Process?
The psoriatic arthritis appears to be distracted right now. I stopped my Humira 2 weeks before my first surgery & didn’t resume until 2 weeks after surgery. But I had almost no pain in my hands for at least a couple months and even then, the pain that returned was less than I was experiencing before surgery. It was amazing to me.
With my 2nd surgery, I also stopped 2 weeks before surgery, took 1 dose 2 weeks after surgery, but immediately came down with a cold so I had to wait an additional 3 weeks for the cold to pass before I could take an additional dose. During that time, I was fatigued (presumably due to the cold) and my plaque psoriasis raged, but my psoriatic arthritis was not that bad. My hands are usually where I feel it first and the pain has been very mild. My foot is still healing and warm, so my body is still sending resources to the inflammation at that site. One of my doctors concurred with this phenomenon of the healing body distracting the overactive autoimmune system. They have heard other patients explain it, but they were not aware of any research in that area.
Anesthesia may also affect the autoimmune process. There is very little known about how surgery impacts the autoimmune process. We need to lobby for more research in this area!
Pain returns
The hand pain returned about 3 months after surgery (September 2019) along with bad shoulder and neck pain. My foot swelled without the boot so I had to go back in the boot and wore it for a month or so anytime I was on my feet a lot. As I look through my logs, I realize I had lots of pain throughout my body until I switched to Taltz in November of 2018. However, within 2 weeks of switching to Taltz, I had 2 migraines about a week apart, a sore throat and sinus drainage that transitioned into thyroid issues and ultimately a Disseminated Zoster diagnosis in April of 2019. I do believe the Psoriatic Arthritis pain was interrupted by the surgery. I initially thought the Taltz was better for my Psoriatic Arthritis Pain, but now that I have received the Disseminated Zoster diagnosis, I am not sure if my body got distracted by that disease and that is what lessened the PsA pain or if the Taltz was actually better for my pain. I may never know, because I may never get back on Taltz, even after I fully recover from the Disseminated Zoster. I started a pain diary since I started this post and am going to explore some of the brain connections to pain more thoroughly. I do believe living with pain for such a long period of time has changed my brain but I also believe that I can practice some techniques to undo some of those pain circuits.
How long to fully heal?
The doctors told me it would take a year to fully heal. That proved true on my right foot. However, I still have what I’ve been told is athletes foot along the scar on my right foot. it hasn’t spread so I’m wondering if that is an accurate diagnosis. I have been medicating it with alternating over the counter medications and they do push it back, but if I stop it comes back with a vengeance. I have 2 more months to get to the 1-year point with my left foot. The surgery was not as successful on that foot. My big toe rolls inward more and I can’t seem to get it straight. The big toe and 5th metatarsal that was cut still hurt some and the skin along the scars is still tingly to the touch so the nerves are not fully healed but I can wear most of my shoes now and have even begun to run occasionally. I am very happy that I tackled these two surgeries and wish I had done it a few years earlier because it has definitely improved my mobility and frame of mind. The pain had become a part of me and was controlling my activities more than I realized.