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X-rays and bone sticking out (Page 1)

I took a pic of my x-rays today. Here's the url to the pic. http://imageshack.us/photo/my-images/259/l egl.jpg/ Is it normal for the pieces of the tibia to be sticking out as they are? Should they have been placed better? I have a sore lump on my leg, my surgeon said it's the bone. Now I know why the lump is there. Thank you for your reply.
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First Helper User Profile Gaelic
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replied September 11th, 2012
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BrokeAgain,

I don't know if the x-ray has been distorted a little in transmission, or if the knee was flexed a little when the x-ray was taken, because it looks a little odd. (From this film, it is noted that you have a segmented midshaft tibial fracture, a segmented midshaft fibular fracture, a proximal fibular fracture, and a medial malleolus fracture. Did I miss any? - Oh, I just edited this post, because I read one of your messages to another member, that you broke your ankle 18 years ago (thus BrokeAgain lol), so the medial malleolar screw may be left over from that, right?)

But, anyways, no, the fragments do not need to be reduced any more than what they have been. They just have to be generally in the vicinity, generally in alignment. To actually reduce each fragment anatomically would require that the fracture to be opened and each fragment fixed with screws, then an antislide plate put on. This actually causes more problems than it solves. The bone gets its nourishment from the surrounding soft tissues attached to the bone. If a fragment is detached from any soft tissue attachment, it is basically dead; it becomes a piece of "bone graft".

This was one reason for the development of the intramedullary nailing technique. Here the reduction is done indirectly, not having to mess around with the individual fracture fragments. And, actually, it is usually not really possible to reduce every little tibia shaft fragment back down. Before the days of surgical treatment, the leg was placed in a well molded cast and any shortening was accepted as part of having injured the tibia. Then, plating was developed, but it could only be done in specific fracture patterns, and they found that even though they meant well, the surgery sometimes caused more problems (because they stripped the soft tissue off of the fragments to put them back in place). That’s when the IM nailing was developed. To allow for the bone to be held in alignment and out to length, but you did not have to disturb the hematoma around the fracture fragments.

However, a segmental tibia fracture is one of the hardest to fix with an IM nail. Trying to get the guide wire down the proximal tibial piece in just the right angle to skewer the middle, segmented piece, then get the wire to go into the distal piece, is a bit of work and finagling. Then, once the guide wire is down, then you have to get the nail down (which is much bigger around of course) through the middle piece also. You want to basically get the proximal and distal pieces to line up properly (using the level of the knee and ankle joints to go by), and then the middle piece is sort of just left to be a spacer in between the other two pieces.


Looking at your fracture fixation, I can’t draw on the x-rays or use the original computer’s angle determination, but grossly overall, the alignment of the tibia looks to be in about ten degrees of valgus. But, remember, determination of angulation has to be done on a true AP of the whole tibia; if there is even a small amount of rotation it throws off all of the measurements. But, if there really is a ten degree valgus angulation that is really more than what is usually considered acceptable. Usually, the goal is no more than five degrees of varus or valgus angulation in the tibial shaft. However, valgus angulation is usually tolerated by the patient better than varus angulation.

(Varus and valgus are terms of angulation when looking at the leg from the front. To give you a quick idea of what they mean; if you were looking at the whole lower extremity and a patient had knock knees, you would say that he/she had genu valgum (genu means knee) and a patient with bow legs would have genu varum. Hope that did not confuse you more.)

When looking at your film again, it appears that most of the angulation is coming from the proximal piece being “kicked” out a little. But, again, this could just be from the x-ray not being a true AP (anterior-posterior) view. Oblique films make the fracture alignment look really odd. And, even just a little rotation of the leg when the film is being taken can really throw everything off.


But, getting back to your leg. I had a couple of questions when looking at the film.

The first, is why was the segmental midshaft fibular fracture not completely fixed? The plate was applied to the lower fracture of the segment, but not the upper. Why was a longer plate not applied, to catch the whole middle fragment? Now, it is possible that the upper fracture was a nondisplaced on, not initially picked up, and has subsequently appeared once it started to heal. But, that is probably doubtful. I ask this, because usually the fibula is not addressed at all. So, if you are going to address the fracture, why not fix it completely while you are there?

The other is, did you have a lateral malleolus fracture? There appears to be some fracture lines within the lateral malleolus. Now, this could just be due to the osteopenia in the bone, which makes it look that way. You have a screw in a medial malleolus fracture, but is there anything going on in the lateral malleolus? Again, without actually having the film (or computer disc) to look at, artifacts can be misleading.




So, you might ask your surgeon about the overall alignment of the tibial shaft. If may be that the surgeon has elected to allow the tibia to heal and see how you do. This is, after all, a very significant injury to that leg. Once everything has healed and you have rehabilitated, if you have problems in the knee or ankle from any residual angulation, then, if you desired, a controlled osteotomy of the tibia could be done for correction. At the time of the initial injury fixation, you have to work with what you are given. And, sometimes, you can only do the best possible at the time, which may not be an anatomic reduction. The goal is to stabilize the fracture in an acceptable position, to be able to mobilize the patient. This is to reduce the chances of the patient developing problems from the fracture and bed rest.


Hope that was not too much information.


Hang in there. You still have a ways to go yet.

Good luck.
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replied September 12th, 2012
Thank you so much Gaelic, once again you're very helpful and informative. I hope I am able to answer all of your questions. Yes, the medial malleolar screw is from injuries 18 years ago. The plate in the fibula is also from 18 years ago. Forgive me for not clarifying that. I had posted in the past but you're so busy I should have never expected you to recall all of that. So that's why the rest of the fibula wasn't fixed with a plate. The breaks above the plate and higher up the fibula are new.

When my leg was x-rayed, my knee was slightly bent. But...I have noticed that my leg does seem to flare outward 'knob knee' somewhat. This began somewhat with the first fractures 18 years ago and I walked with my foot pointed outward. I really have noticed it with this new break. I thought maybe it was the atrophy giving the illusion of it mis-shapen. The doctor hasn't said anything about it.

I don't know if I had a lateral malleolus fracture. 18 years ago I was told I broke my ankle in three places and that's all I knew. I know of the obvious places by seeing the x-rays and hardware.

I hope it all works out, my surgeon was very concerned about me not healing in the beginning. This last visit he didn't seem either way with my healing, said it is and will just take time. I know it's a long road and I hate the uncertainy. I've been no weight bearing for 2 months and he said still none for two more months.

What are your thoughts about the lump I have? It's about the size of a half of half of a hard boiled egg cut long ways. It swells and is very sore. My doctor said it's the bone.

I hope I answered your questions. Once again, thank you so much! I wish my doctor was to explain as well as you do.
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replied September 12th, 2012
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BrokeAgain,

If the lump gets bigger and smaller, it is not totally the bone. That is more likely some inflammation within the soft tissues around the healing fracture.
The soft tissues around a significant fracture will often develop what is called "woody edema". This is due to some fluid in the extracellular spaces, but also from the formation of fibrous tissue around the fracture, a type of scar tissue.

But, lumps are very common in tibial shaft fractures. They can actually get to be pretty good size, depending upon how much callus formation the body makes. Sometimes, they will eventually decrease some, as the bone remodels, but usually not too much. Adults do not remodel bone like kids do.

Yours may also be a little accentuated because of the way the proximal tibial fragment appears to be “kicked out” some. Usually, where those step off are, where the bone fragments come together, those will fill in with callus formation, smoothing the surface out some. When that occurs, the lumps are usually not as noticeable.


You have a pretty significant injury. This x-ray does not show a lot of callus, but the fragments’ edges are starting to become “fuzzy” and rounded a little. This is an early sign of fracture healing.


Try not to get discouraged. It’s hard, but you can do it. This too shall pass, it just takes time.

Hang in there. (You answered my questions just fine.)
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replied September 14th, 2012
Thanks again! I think it's more difficult mentally than physically.
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replied September 15th, 2012
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No doubt. Hang in there.
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replied September 28th, 2012
Gaelic, I know it's impossible to know for sure but if you were to guess how long my segmental tibial fracture would generally take to heal, how long would it be? My surgeon doesn't know. I hate not having a rough idea. Thank you!
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replied September 28th, 2012
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BrokeAgain,

You are about 11 weeks out from your injury/surgery and the picture in the first posting of this thread was at 8 weeks out.

So, yes it is difficult to tell how long it is going to take. But, with that amount of trauma, with a segmental piece, and all of the periosteal stripping, the callus formation is going to be slowed down some.

I would predict that is would slow it down from the time for a low energy tibia fractue to that of a high energy one. So, insteed of 10-13 weeks, it will probably be more like 13-16 weeks or longer. However, I do not think that it will go past 20 weeks.

But, again, this is just an educated guess, as there is nothing absolute in medicine.

I know it is frustrating, but you are just going to have to hang in there. Good luck.
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replied September 29th, 2012
Thank you. I know it's not absolute.
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replied October 21st, 2012
Hi Gaelic, it's me again. Ever since I broke my tibia and fibula I've had pain and numbness in my toes, mainly my big toe. I can move them ok but lately the second toe has become more painful and I feel a tightness and pressure on the top of my foot directly below the toe. My big toe is pointing somewhat upward and the second toe seems to be lower or 'drooping' more than the others. It's giving the illusion of the second knuckle bending the opposite way. I have quite a bit of swelling in my toes and foot. So I stay elevated as much as possible. I've been no weight bearing now for over 3 months. Do you think my toes are like this because I haven't been walking? When I wrap them in an ace bandage they feel some better. Also, my ankle which was broke 18 years ago has been aggravated from my new fractures and I'm experiencing a lot of swelling and aching in it. Is this to be expected? My actual fracture sight is pretty much pain free. Thank you so much in advance
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replied October 22nd, 2012
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BrokeAgain,

Sorry you are still having problems.

As to the numbness on the top of the foot (dorsal aspect), that could be from injury to one of the peripheral nerves. It is not uncommon for the common peroneal nerve (which divides into the superficial and deep branches) to be injured in tibia fracture, especially ones in the proximal part of the tibia (like yours). This nerve supplies sensation to part of the foot, mostly the dorsal aspect (superficial branch) and the first web space (deep branch).

Usually, if the swelling is causing numbness, it is in more of a “stocking” like pattern. So, the whole foot would be numb, rather than just part of it.

Unfortunately, it is very common for the toes to “deform” after significant trauma to the lower extremity. The muscles which move the toes are actually located in the leg, under the gastroc/soleus complex, mostly in the deep compartment.

You might want to do routine massage on the toes and foot. Also, passively putting the toes through full range of motion, while you are massaging them, will help to keep the joints supple. Of course, active range of motion is necessary to keep the tendons from scarring down, and to help rebuild the muscles.

You might look into some compression stocking, since the ace wrap seems to help some.


But, again, it is not uncommon for patients to note that their toes are acting “funny” after tibia fractures (and other significant injuries). Keeping the joints supple and preventing the soft tissues from developing “woody edema” are about all you can do at the current time. Once you start to walk and put weight on the foot again, it may help with the toe problem. Again, keep the joints in the foot as supple as you can.

If you start to note that you are developing “nerve pain” in the area that is currently numb, you might ask your surgeon about some of the medications that are used for neuropathic pain, such as gabapentin (Neurontin) or pregabalin (Lyrica).


If the problem seems to be getting worse, mention it to your surgeon, so he/she can evaluate the situation, to make sure there is nothing else going on.

Good luck. Hope your bone is healing, so that you can get on with your rehab pretty soon.
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replied October 23rd, 2012
Thank you! I go back to my surgeon Nov. 12th and hope to hear some good news. Thanks for the wonderful information as always.
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replied November 9th, 2012
It's me again Smile I went to see my surgeon today, it's been 4 months no weight bearing. He said he didn't see a lot of healing but gave me the ok to try 50% weight bearing. I was kind of shocked it was that much but I assume the IM nail is going to take on much of the load. I lost my insurance (long story) and because of this I will not be having physical therapy. I was hoping you may be able to offer some advice and tips on what I can do. I don't even know how to put my foot flat on the floor in a standing position. I tried a little weight bearing and it was all ball and toes. I did sit on the side of the bed, flat footed and applied some pressure. I could feel things stretching, it felt good. I use a walker and was also wondering if it'll be possible to use a cane at 50% once I get moving more? I go back to my surgeon in two months. I didn't think to ask him all of these questions when I was in his office and besides, he was trying to rush out of the door. Please, if you can help me any it would be appreciated as always.
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replied November 9th, 2012
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StarShine12,

It just takes some practice, getting use to putting some weight on the foot. Sitting on the bed, or in a chair, is a good idea to start to get your foot flat. It is very controlled and you do not have to worry about falling.

The best way to get an idea of how much pressure 50% weight bearing is, is to use your bathroom scales. Using you walker or crutches, stand with your good foot on the ground and your injured one on the scales. Apply pressure to the injured foot/leg till the scales reach half of your body weight. Do this several times, till you can get a feel for how much pressure is equal to half your body weight. That way, you will know about how much to apply when you are walking with your walker/crutches.

As to the cane, yes, a cane can take up to 50% (not any more) of the body weight off of the lower extremity, when used in the hand opposite the injured limb. But, you have to have a pretty good command of your gait before going to a cane. You should be able to walk with a fairly normal gait, using your walker or crutches, before going to the cane. A cane does not provide much stability at all.


As to physical therapy, most of it you can do at home. You need to work on range of motion of the ankle, knee, and hip. As to strengthening, most of that will have to be done once the bone is healed well enough to walk. Walking is a great exercise, it strengthens the muscles and builds endurance.

But, you can get some ankle weights, place them around the ankle and while sitting in a chair, straighten out the knee. This will work on strengthening the quads. As long as you do not put extremely heavy weight on the ankle, it will be okay.


With all of your activities, if you start to develop sharp, intense pain right at the fracture site, you need to back off just a little. But, aching or soreness in the muscles is okay, and actually is to be expected.


If you can get to a swimming pool, doing exercises in the water is a great way to rehabilitate. The warmth of the water makes the tissues more pliable. The buoyancy makes the exercises partial weight bearing to essentially nonweight bearing.


Good luck. Hope you do well in your rehab.
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replied November 9th, 2012
Thank you! By the way, I'm also BrokeAgain. I couldn't recall which email and password I used.
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replied November 10th, 2012
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I sort of figure that was the case. I know you are not supposed to do this, but I have to write all of my user names and passwords down.

Hang in there. Hope everthing goes well for you, and this leg finally heals.

Good luck.
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replied December 23rd, 2012
Hi Gaelic, unfortunately I'm not able to go away from this board. Though thankful for the advice I'll be so happy when I don't need it anymore Smile

Anyway, a quick question please. I'm almost 6 months postop, slow healing and am struggling with 50 % weight bearing. No PT so I'm winging it. I have a new burning pain at my fracture sight. I usually don't have too much pain there and when I do it's more of a familar bone pain. This burning is totally new. Other than that there's no other new symptoms. My OS said I could "try" the 50%. Could it be it's too much? I try to pay attention to the pain in the fracture sight. My muscles feel ok so I don't feel I'm over doing it as far as muscles go. Thanks for your time.
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replied December 23rd, 2012
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BrokeAgain,

It is always concerning when a new pain crops up out of the blue. But, it may be that you are just overdoing it a little.

If there are no other symptoms, such as swelling, redness, or warmth around the fracture site, it is probably just part of the healing process. Some of the nerves around the injury could be overstimulated. It is always difficult to determine exactly what is going on.

Usually, if you went to the surgeon, a new x-ray would be taken. If there was nothing new on the film, you would be advised to back off a little on the weight bearing and see "how it goes". So, you might want to do that for a few days over the holidays. If the pain gets worse or you develop other symptoms, contact your surgeon to see what he/she wants you to do.

You might try some heat on the area (hot packs or hot tub). Heat is usually more soothing than ice. However, if the pain is sharp, you might try ice first.


Sorry that you are having a new problem. Hopefully, it is just temporary.

Hang in there. Try to have as good and happy of a holiday as you can.
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replied December 24th, 2012
Thank you. I see my surgeon Jan 7th. I haven't done much today but so far I haven't had any burning pain. I wish you a happy holiday as well and thank you so much for the wonderful service you've given this board!
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replied December 24th, 2012
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BA,

No problem, answering questions here on the forum keeps me busy and out of trouble. And, I enjoy doing it. Let us know how your appointment goes, good or bad.

Hang in there. Good luck.
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replied January 7th, 2013
Hi Gaelic and all! Gaelic you mentioned that I post after I saw my surgeon. My doctor said that one part of the tibial break looks about 70% healed and the other 50% (we don't even discuss the fibula) He said with these types of breaks one part can be healing well and the other not. BUT...I got the ok to slowly build up to full weight bearing!!!!!!!! I'm so happy!!!! I go back in 3 months and if I'm not healing well he's going to remove a couple of screws from the rod, that can stimulate healing. I also got the ok to drive as long as I feel comfortable. I don't think I'm quite ready but I'm getting psyched and excited!
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replied January 7th, 2013
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BrokeAgain,

That is great news. Hope you heal well, but if not, the dynamizing of the rod can help to stimulate to bone to finish healing. And, that is a pretty easy surgery, to remove a couple of screws.


As to driving, be sure that you feel completely safe before trying. We usually tell patients, that if they feel safe enough to drive, if their children are in the back seat, then they are probably okay. But, if they would not risk their children, then they are not ready.

If you are not sure, have someone drive you way out in the country, some where isolated, where you can get behind the wheel for a little stretch and see how things go. If you feel okay, then drive a little further.


Be advised, there was a study done, on patients with tibia and ankle fracture, and their reaction time for braking in a car. It was found that people with lower extremity fractures had slower reaction times for braking for more than a year.

So, just adjust for that. Take it easy, allow more time for reactions, and leave extra room between you and the car in front of you.


Good luck. Hope you are back to driving soon.
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replied January 7th, 2013
Thanks for the info and well wishes. I'll keep it in mind. My first fractures were from a car accident so I really can respect what you said. I'm excited but I will not do anything till I'm sure I can handle it phyicaly and mentally. I'll practice like you said first.
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replied February 12th, 2013
Hi Gaelic. I'm still struggling with full weight bearing. I mainly use a walker but am able to use a cane or one crutch for short distances. Very short. I believe all of this time off my feet has made my muscles weak but I'm having a lot of anterior knee pain. I have told my surgeon about this and he just shakes his head and agrees with me, it's to be expected. I've done some research on the web and know that knee pain is a common side effect with the IM nailing. Lots of information out there that the surgery causes this but nothing to be found as to what can help it (other than hardware removal in some cases.) I was wondering if a knee brace would help? Any suggestions? Thank you.
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replied February 12th, 2013
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BrokeAgain,

Unfortunately, there is not a whole lot of do about the anterior knee pain. The recommended treatments include maintaining range of motion of the knee as much as possible, quad strengthening, hamstring stretching, ice/heat as needed, NSAIDs as needed, and the use of a neoprene knee sleeve.

A big bulky ligament brace is not really needed, just find a sleeve (with or without a patellar cutout) that is comfortable for you. Basically, it is to provide some warmth, compression, and maybe some proprioceptive feedback. The main thing is that it is comfortable.

Unfortunately, there is not much the orthopedic surgeon can do. The best thing is to try to avoid the anterior knee pain in the first place, by trying to avoid entering the joint during the procedure and try to not bang up the patellar tendon either. But, even when the procedure is done flawlessly, some patients still develop anterior knee pain. Don't know why.


Hope you can get back on your feet soon (no pun intended). Keep working on your rehab. Good luck.
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replied May 28th, 2013
Hi Gaelic. I'm still around unfortunately. It's now over 10 months since my segmental tibia and fibula. I can walk unaided for short periods, use a cane for short periods but for long hauls I am STILL using crutches and sometimes a wheelchair. The knee pain isn't as bad anymore but I had a newer radiating pain that feels almost like an electrical current...even a metallic feeling. I'm also experience a huge amount of swelling. My lower leg muscles are small from atrophy but with the swelling they become hard and large. My ankle looks like half of a small baseball on both sides. I can sometimes barely bend my toes. The swelling does go down with elevation and ice but it takes no time for it swell badly. I'm very concerned about this and I'm so frustrated and miserable. I see my surgeon on June 3rd. Is this type of swelling to be expected? Thank you.
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replied May 29th, 2013
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BA,

Not usually. Most of the time, the amount of swelling and edema a patient experiences tends to go down as time goes by.

You have had a lot of damage to the tissues in your leg, and as such, the veins and lymphatic channels have had to be reformed. As these new tubes grow, they allow for better blood flow and movement of the lymphatic fluids.

Of course, the venous blood, lymphatic fluid, and edema have to have muscle action to get back into the core of the body. So, again, as the tubes reconstitute and you start doing more and more active range of motion and strengthening, the swelling should become less and less. But, you may just be a little slower than most patients.


You might want to get some compressive stocking (support hose). These will help to push the fluids back into the "tubes" and will also help to keep the edema and swelling from forming in the first place.

You can get several different types of compressive stockings. There are the type that you can get at a department store (fashionable). You can get the "medical type", such as TED hose or Jobst stockings, which they use in hospital settings to help reduce the chances of developing DVTs (deep vein thrombosis) or to help with burn scars and lymphadema. And, then there are the types which are worn by athletes. These last types come in all sorts of colors, styles, and sizes.


So, again, try the compressive stockings and continue with your rehab. You have had a lot of damage to your leg. It is not uncommon for it to actually take a couple of years for all of the soft tissues to mature and finally settle down. Talk to your surgeon about the swelling. But, he/she is probably just going to tell you to get some compressive stockings (lol).

Hang in there. Wishing you the best.
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replied May 31st, 2013
Thanks as always Gaelic! I got the sport sock-like compression and there's already a huge difference. I've been wearing leather ankle boots on top of that and they help too. A little hot for this time of the year but it feel so much better! Best wishes!
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replied June 1st, 2013
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BA,

Glad you are doing better. Hang in there, you have gotten this far.

Wishing you the best.
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