I'm an old man who has sustained many injuries. I had planned to write this first part of the physical fitness section, the "Off the Couch-Injury Recovery," section based on previous experiences I have had recovering from injuries.
By an amazing stroke of luck I took a whole new injury in early Jan of 2011, so this section is being written from the bottom-up, describing recovering after incurring a debilitating lower body injury. The effects of this injury have touched and reinvigorated earlier injuries, making this a complex recovery from both the primary and secondary injuries. Here's the deal.
You may find the following recovery information useful even if your lower body injury is not frostbite. The frostbite caused internal "structural" foot damage throughout the front of my foot consisting of damage, degradation really, to bone, muscle, and soft tissues. This is typical of many foot injuries. My knees, hips, and back seriously deteriorated during the first couple of month's inactivity after the initial frostbite injury, making this a complex recovery.
The key is to apply the following techniques of observation, analysis, and feedback to your particular injury situation. and sensitivity and feedback to your particular injury.
After four nights backpacking at high elevations in very cold temps during early Jan of 2011, I exited the Meiss Roadless Area in the Lake Tahoe Basin to have breakfast at the Downtown Cafe in Meyers. The fine couple that owns the cafe are very backpacker friendly. I de-booted and de-layered there, next to their gas stove, exposing and gently warming my perfect pink feet. After four nights in the High Sierra snows both my feet were fine.
My mountain gear includes down booties with two layers of insulation socks for camp. Camp gear is complimented by my excellent Zamberlin mountain boots for daytime travel. My daytime travel sock system mixes thick wool socks with poly liner socks. The conditions determining the specific setup. I had the setup for the conditions, and properly used it in the mountains.
This system works exceptionally well for mountain travel during Winter. My problem was that I had no proper gear for hitchhiking. Standing idle on a frozen/slushed roadside suited neither my trail gear, which was set up to stay warm during movement, nor my down booties. The down booties were warm enough for standing idle in a snowcamp, but were completely insufficient for the slushy roadside conditions. I needed gear for conditions that I had not anticipated. I also had an unusual boot/foot problem.
Upon warming myself in the Downtown Meyers Cafe, my Right foot swelled up slightly. I took note of this when I re-booted after breakfast to hit the road home. This swelling was an interesting side-effect of bringing myself up to normal temps after five full days in low temps. This made for a tight fit for my Right foot in my Right boot. This turned out to be a very damaging turn of events.
Putting myself back into cold temps after my foot swelled up in my boot began to cut off circulation to the front of my foot. After two and a half-hours of hitchhiking pain, both in and out of the kind people's trucks who picked me up, I arrived in Sacramento, where I felt I could finally unboot after getting out of the cold and snow conditions. And it was an ugly package I unwrapped.
I incurred the foot injury pictured below on Jan 5 2011. As of this writing in late July of 2011 I am currently in the end stages of recovering from the skin damage caused by frostbite and the attendant loss of circulation to adjacent tissues. I have been fairly sedentary for seven months now since incurring this injury. Here's how the injury presented 5 days after getting off the trail.
It took a long time for the damaged skin to die and begin sluffing off.
Evaluating the Extent of the Injury-First Response
The loss of circulation did not just damage the skin. The tendons, ligaments, muscles and bones in the front of my foot, what I call the "structural" elements in the front of my foot all suffered from a lack of oxygen. The structure of the front of my foot experienced various degrees of degradation and injury to the soft tissues and bones. Practically speaking, I'm talking bone and muscle aches, pain, and weakness.
The loss of circulation to the end of my Right foot was mostly centered in the big and second toe, but generally affected the front of the foot. The extent of the damage was from the tip of my toes to the heel-end of the front footpad. I initially lost all feeling in the front of my foot, including all toes.
The Long Term Nature of Frostbite Injury
The first three months after the injury were characterized by almost complete inactivity except for fulfilling the most fundamental personal needs that required walking. As the injury resolved itself large patches of skin went over to the dark side. It was two months from the point of injury before the injury stopped progressing, and I could fully assess the full extent of the injury against my original assessment, and finally begin healing.
This was the point where I won the argument with the doctors: the deepest extent of the loss of skin, circulation, and sensation was not sufficient to justify amputation, and by two months from the time of the initial injury I had been able to initiate waves of skin growth that would grow and sluff off, and then grow again. As each one of these waves of skin surfed through the front of my foot, then peeled off, it brought greater and greater circulation and sensation to my toes and footpad.
Starting with degraded circulation and no sensation or sensitivity to touch the end of my Right foot first gained the ability to feel pain, then a heavy touch, and now experiences the sensation of a very light touch. Except of course the very dead tip of the big toe pictured below.
From being unable to support weight at all my front footpad and toes can now support my weight through an almost normal gait. I still cannot fully complete my gait through my Right foot due to the nerve sensitivity and the open wound at the tip of my Right toe. But I'm getting closer to getting my big toe to carry full weight and stress.
You particular history of previous injuries becomes very important anytime you incur a new injury. My frostbite injury has caused a lengthy period of inactivity, which has in turn stimulated many of my previous injuries, and generally damaged my overall fitness.
Sitting and recovering for extended lengths of time has the potential to degrade all of your previous injuries, and will generally degrade your overall fitness.
Check the physical preparation introduction/index page for an introduction into how to accodomate your previous injuries to your new fitness program.
The pressure ridge visible on the toenail pictured above was caused during extreme cross-country backpacking action during the Summer of 2010, which had pulled off this same toenail. Though it looks weird, it was not part of the frostbite injury.
All of the subsequent replacement toenails have all grown back in with the same pressure ridge as pictured above, but moving up as the toenail continues to grow.. The pressure ridge has been an enduring physical remnant of that hard trip.
Though I have finally lost a series of toenails due to the frostbite, the pressure ridge continues to manifest itself on each subsequent toenail that grows in.
The Summer Trip of 2010 where I got the pressure ridge on my toenail was actually a pleasant experience, besides bringing a rash of blisters and the slow removal of my big toenail. Really. Despite the pain of losing the toenail and creating an enduring pressure ridge on the subsequent toenails, that trip was a real blast...
I have never had a previous injury which has brough together the skin, nerve, and soft tissue damages caused by losing circulation due to frostbite. Wow. I have previously had external wounds. I have previously had internal soft tissue / structural problems in my feet. I have had nerves and blood vessels cut and stitched back together. I've seen my own bones a few times.
But I have never had all of these particular problems all at the same time. Wow.
My previous structural foot problems had been caused by stress rather than a loss of circulation, though the resulting structural pain and weakness in the foot feels much the same despite their different genesis. I am applying the same program that I employed for my previous structural problems in my feet: Hot Water, Massage, and the "beer bottle roll."
This type of dull aching structural pain in my Right foot indicates that I need to devise a program of gradual strengthening to slowly build endurance while being very careful not to overwork the frostbite weakened muscles and soft tissues. You must be very careful not to further the injuries as you attempt to rehabilitate them. My first therapies were designed to gently encourage and stimulate circulation to preserve good skin and rescue the bad skin.
Massage, hot water soaks, elevation to drain the blood out, and doing it over again were supplemented by gently rolling my foot around on a 12oz beer bottle. Yup, the best device I have for massaging the bottom of my foot is a 12oz beer bottle. I can roll my foot around on the beer bottle to focus massage on the front footpad and front part of my foot's arch. All of this is complimented by short walks, where I attempt to put increasing weight on my front footpad and consider rolling my weight up onto the toes.
My goal with the warm water and massage is to improve circulation and stimulate healing. The walking is stimulating all the injured parts.
At the same time I have had to carefully monitor the effects of walking on the damaged skin and nerves to prevent further damage from contact with the shoe. Very careful walks help restore circulation, strength, and endurance in the totality of the foot structure.
Proper amounts of walking also helped stimulate the skin growth as well as strengthening the structure of the foot, but I was very careful not to overwork either aspect of the injury, the external damage to the skin, nor the structural damage to the soft tissues within the foot.
As a significant aspect of the injury involves the open wound at the tip of the big toe, keeping the wound sterile throughout the therapy and exercise program is vital.
Injury: Wave after wave of major blistering, dying skin at the tip.
The Therapy Bucket.
Peeling the skin after the blisters popped and the skin hardened worked out best for me.
Very warm, but not hot, water.
Just the tip of the iceberg of supplies.
Beer is good for circulation.
Sponges, gauze, tape, sterile sissors, antibiotics (in case of infection), antibiotic cream, and much more.
From the very first day of arriving back to civilization to the present day I have been employing a daily regime of hot (warm) water, lubricated foot massage, elevating the foot, extreme sanitation/sterility practices, and aspirin to thin my blood for better circulation to the frostbitten extremities.
Each full cycle of hot water heating, elevating, massaging, aspirin and cooling my damaged foot takes two hours. I surge hot blood into my foot by being submerged in the bucket of hot water, then elevate the foot to drain it of blood, then constantly repeat the cycle for about 70 minutes, puncuated by constant gentle massage.
For the first six months after the injury I did two cycles a day, only dropping down to one hot water therapy session a day after the external skin damage was finally narrowed down to the very tip of my Right big toe, and the structural pains diminished.
The hot water therapy and massage sessions are as vital for repairing the internal structural damage to the bones and soft tissues in the front of the Right foot as it is to stimulating external skin growth and improved circulation.
A couple of months of this hot water and massage therapy was the very first step towards getting the front footpad strong enough to begin to bear weight. This hot water and massage therapy has been vital to restoring the soft tissues in my front footpad enough to begin to bear my weight.
This then allows me into the next phases of recovery: stretching and walking with weight on the footpad. The next goal is being able to roll my weight forward onto my toes, and especially my big toe.
Walking and Stretching are the fundamental foundations of backpacking fitness
Last Video: Intoduction to Stretching. A nice walk to my stretching wall.
Inactivity compounds old injuries
The inability to walk after the injury immediately started to put stress on my previous knee, back, and hip injuries. Being unable to exercise these previous injuries started to degrade their conditioning, which shortly brought on increasing tightness, chronic pain, and weakness.
The negative effects of injury are not just limited to straining previous injuries. Inactivity reduces the efficiency of your heart, lungs, digestive system, and generally degrades your whole body.
Secondary Injuries Kick into Action
Two months from incurring the frostbite my hips, back and knees were beginning to weaken and tighten up significantly from inactivity. Back and hip pain levels were reaching the same levels as the foot pain. Restoring basic function in my foot was becoming important to stop the degradation of my previous injuries. It was becoming a race: would I recover enough mobility in my damaged foot fast enough to prevent my knees, hips, and back from falling apart?
Hot water, massage, elevation, and blood thinner (aspirin) were the stimulus I employed to restore both the skin and deeper tissues within the front of my Right foot and toes. As the circulation and sensation was restored within my foot by hot water and massage the bones, muscles, ligaments, and tendons were also beginning to respond by strengthening themselves from their degraded state. But I had to "push" the foot structure to respond, within careful limits. I set myself goals for walking. First just short distances around the house, then greater and greater distances in the neighborhood, and finally up the ridge behind my place.
I monitored the standard level of pain, the extra pain caused by walking on the foot, and the duration of increased pain after walking to determine how far I could walk without further damaging the degraded tissues or triggering sustained extreme pain.
Without the ability to fully engage my foot with the water therapy/massage, and focus the rest of my attention on sanitation and sterility the doctors may well have been correct about losing the two biggest toes, if not the front on my Right foot. I am convinced that the stimulation of the constant hot water and massage maximized the healing and recovery of tissues that would have otherwise been lost.
Also vital to recovery was the fact that as soon as I was capable of putting weight on my foot, I did. The stimulation of putting weight and walking on the foot as possible was and is still vital to healing. The realm of possibility for my foot is now walking out of the land of injury recovery, and will soon be running down the trail of a growing backpacking fitness program.
Step by small step I have gradually added to the length and time I can walk as I restore skin, circulation, and sensation to my foot. Though I am not officially in my "training" program because I am still in the "healing" phase of recovering from this injury, the requirements of building up even the most fundamental physical capacities of injured parts requires a mini-training program of its own, even as the healing process continues towards a "successful" termination. Though I am now carrying a whole new range of pain, I am still walking on all ten toes.
The painful progress of healing will gradually transform itself into a painful progression back to full health and fitness. As I have continued to repair skin and structure, I have extended my walking and stretching program.
Stretching Three: Final Stretch, Final Thoughts on tracking down and eliminating trouble, Repetitions, and Duration.
Below: Note the expanding split between the live and dead skin on the right side of the black patch on the tip of the toe. I could feel this split happening, as I could also feel the nerves and blood vessels dying as it did. This picture may be the best explanation of why I have dubbed 2011 my own personal "annus horribilis," the bad year.
Early in the process when my big toe was splitting open things looked ugly all-around. Frkn thing looks like a partially burned hot link splitting open on the grill.
Below: We can see the dead skin mummifying.
Drugs and Pain
I have a high tolerance for pain. But enough of that bullshit. The VA has issued me bottles of 56 30mg Morphine Sulfate as quick as I use them. I quickly worked out a "two days on, two days off" system to prevent over-dependence or developing too high a tolerance to the Morphine. By the end of the second day without Morphine the pain reaches serious levels. By the end of the second day on Morphine I'm sedated enough to get through the next day without drugs.
As I said, I have a high tolerance for pain. In mid-June I gave up the Morphine for 30 mg codeine as my pain diminished across the overall area I experienced it, as well as its duration.
But as my pain had not diminished in intensity, though the scope and duration of the pain had diminished significantly, my wonderful NP Annie Stratsky urged caution in too-quick a reduction in pain killers. But I am stubborn. When I say I'm quitting Morphine, I'm quitting Morphine.
After a two weeks of brutal pain without the Morphine, I asked for ten 30mg Morphine to help me reduce my outrageous Codeine consumption, while hoping this powerful drug would afford me a few hours of peaceful sleep. My NP at the VA, C. Flores laughed, and suggested that he prescribe enough Morphine to carry me through what he predicted would be a future full of sustained pain.
Though the doctors have finally given up on predicting my toes will be amputated, they have now taken up predicting that I will experience "neuropathy," a condition of perpetual nerve pain from the frostbite damage. I laughed at him. I have already reduced the pain's duration and breadth by 50%.
This reduction in pain will continue until this foot bothers me no more than any other body part I have previously damaged, if my recovery program works as well this time as it has in the past. It generally takes two years from the point of serious injury to nerves to reduce the residual nerve pains, and maintain nerve and soft tissue pain at or below the "chronic" level.
But I'm not there yet. I happily took Doc Flore's prescription for the 56 Morphine!
Some basic Principals of Pain Management
Pain management is vitally important for healing and recovery. Severe pain retards healing, enhances inflamation, fatigues the injured part and is generally exhausting. Severe pain can cause muscles and soft tissues to tighten up around the injured area, which can reinforce a feedback loop of pain: The injury causes muscle tension, and the muscle tension irritates the injury.
Then you go crazy.
Pain Management is a vital part of healing and recovery, but has its own drawbacks that must be accounted for in your plan.
First, pain medication's masking of pain makes it difficult to ascertain the actual status of the injury. Pain medication must be regularly cleared from the system so you can exactly determine the nature and extent of your injury. This also does a real favor for your kidneys and liver, which are tasked with processing the narcotics and anti-inflamatories.
My basic manipulation of pain medicine is time on, time off. Besides allowing a clean assessment of your injury and level of pain, taking time off narcotic pain killers reduces your tolerance level to the drug to maintain its effectiveness.
During first two months after the injury the full extent of the frostbite damage revealed itself. A series of blisters grew over the extent of my big toe and the tip of the second toes.
As I mentioned above, I was already spending four hours a day on my hot water/massage program to first preserve, and then restore what skin and feeling in my right foot that I could, while simultaneously growing back the skin I lost on the tip of my toe.
I found that I could not wait for full healing of the skin or sensation to start working on my basic ability to walk. The problem is that the inactivity caused by the frostbite injury is degrading my previously injured back, knees, and hips. Either I started adding strength, endurance, and flexibility to my foot before the skin was healed, or I would lose too many other body parts.
I had three factors to terminate before I could begin walking. First, I had to restore enough circulation to the skin on the front of my foot so that the pressure of wearing a shoe would not reduce circulation in the skin, thereby promoting further tissue loss. Second, I had to settle down the nerves in my foot enough so that wearing a shoe would be bearable. Finally, I had to strengthen the front footpad enough to be able to bear weight. It took three months of constant therapy before the basic conditions of the foot improved enough to bear short distances walking in normal tennis shoes and begin stretching and flexibility exercises.
The first stages of the process of getting the skin ready to walk involved shedding the layers of dead skin as the dead skin cap at the tip of my toe very very slowly resolved itself to reveal the final extent of dead tissue. In the meantime fresh skin began spreading under the dead sections, forcing them into shrinking perimeters, and shedding superficial layers of skin that had been damaged. During this process I was walking as far as the pain would permit. Walking was necessary to stimulate both the skin as well as the bones and soft tissues. For the first couple of months it was challenging to just get around the house.
Though I had the ability to bear the pain and walk further, any more activity greater than very short "hobbles" during the earliest stages of the injury could further damage the skin and retard circulation, so I avoided walking as much as humanly possible for the first month after the injury.
Above: working the snake-skin voodoo thing. I produced endless blisters and shed many layers of skin during the first couple of months of recovery. All of my calluses "detached" themselves, and peeled off the underlaying skin of my foot just like a small piece of wallpaper peels off your bedroom wall.
Below: the full extent of tissue loss became apparent when the tip of my toe up and died. I was quite happy with this outcome, compared against the sugeron's predictions of the first two toes dying, with amputation following. If that did not go well, they would remove the whole front of the foot. So said the doctors. From that basline diagnosis I recovered both toes.
From the point in time below, my goal in life was to regrow skin over the bone at the tip of my toe while preventing infection.
Below: The second toe shed more than a few layers of skin, and the toenail just fell off. The skin on the second toe did not die down to the bone as it did on the tip of the big toe. The remaining good skin on the second toe was frantically growing new layers of skin under the damaged layers to make up for the injury to the surface layers. Second toe was working overtime!
The bottoms and tips of all my toes had no sensation for a few months, then nothing but pain for a few months after that. I was thankful when the pain came, as it indicated that the nerves were coming back to life in their own special way. After 7 months of healing sensation in the front of the foot it is now feeling totally normal about half the time. The other half of the time it appears that my toe has taken part time jobs as a fire walker and barbed-wire tester.
First Exercise-Stretching Sessions
I began light walking on each part of my foot at the point in time when the damaged skin demonstrated that it was fully circulating blood through the tissues when my foot was in the shoe. I knew if the circulation was good by feel. The nature of the pain told me if it was the normal pain caused by walking on my damaged nerves and tissues, or if the pain was the screaming dull ache of poor circulation.
Once the bottoms of the front footpad and toes began to show life, and the tips of the toes began to show signs of good circulation, I began to gingerly apply weight across the front foot pad and have recently begun rolling the weight of my step onto my toes.
Once I first started hobbling around this light walking activity stimulated better circulation throughout my foot, stimulated wound healing on the tip of the big toe, and began to strengthen the damaged internal soft tissues. And it hurt like hell. During the earlier stages of my aggressive walking program the bottoms of my toes and front footpad showed excellent progress towards developing the basic strength and endurance I needed to recover the ability to walk normally.
As each part of my foot recovers circulation, sensation, and skin I work the foot harder. Each level of work is beneficial the foot's status and works to bring even greater circulation, strength, flexibility, and sensation necessary for the next level of healing. Over time I hope that this approach will gradually bring my foot back to normal levels of strength and endurance without leaving too much residual pain for too great a time into the future.
I am adjusted to the concept of long term pain, as previous experience tells me to anticipate the nerve pain to reduce within about two to two and a half years after severely damaging nerves.
Skin peeled off, flaked off, and sometimes just turned black and stuck to the underlying tissue, and then was itself sluffed off by the new growth of the underlaying skin. I stimulated it all with warm water, massage, and very cautious exercise, complimented by extreme sanitation and sterility practices. As each surface layer of skin died I was stimulating my foot in every way possible to bring the next layer of skin up to speed as quickly as possible.
The front of my foot and big toe are not normally so "fat." The whole front of my foot was swollen, and swollen painfully, both from the internal damage to the soft tissues as well as the damage to the nerves caused by the loss of circulation. Soft tissue and nerve pain are double edged pains. Both pains have their own specific characters that express themselves differently during injury as they do during recovery.
Below: At the point of time this photo was taken, about three months from the time of the original injury, the dead and live skin have finally distinctly resolved themselves. The end of the toe bone is actually sticking out from the flesh under the dead skin cap. I saw the X-ray. Whoa! But not to worry: Like a starfish or lizard my skin has been"welling up" and growing up under the dead skin and above the bone for the last four months, to re-cover the bone with fresh "baby skin." Pretty good for an old man, eh?
Want to know what I'm really thinking? Imagine a stubbed toe on nuclear steriods:
Below: Early July 2011. As you can see from the difference between the pictures above and below, my toe is no longer shedding vast amounts of peeling skin. All the toes have their final coat of skin, except for the tip of the toe, where the circle of flesh is getting smaller every day as it ever so slowly draws the wound to a close.
Despite the fact that the skin on the tip of my toe is growing well, and is growing under a nifty protective cap of dead skin (god, the surgeons hate anyone having any dead skin on their body: they always want to cut it off...), I still have a small open wound at the tip of my Right big toe which still presents a risk of infection.
Seven Months Out
Seven months from the original injury my toes and front footpad are still swollen. Note the difference between the length of the toes on each foot. The swollen footpad on the Right foot still makes the right toes appear shorter than the length of the toes on the Left foot.
I am hiking 4.5 to five miles every two or three days in the hills on these feet, and I am now jogging up to 2 miles of this distance. I am having some real problems with my previous knee and hip injuries which is occassionally causing multi-day recovery periods.
Hiking the bad foot up to the top of the Berkeley Ridge on fire roads and trails reveals the Golden Gate and Alactraz.
Below: August 2, 2011, Eight months after incurring the frostbite injury. Wow. Who could complain about this good ending, when it started so ugly, and looked so bleak, for so long.
Above: Note how the skin is "pilling" up, as the dead skin retreats to cover the bone extending beyond the in-growing new skin. Amazing.
August 2011: Seven Months Out
As indicated by the image above of the tip of my Right toe, the big toe bone is still sitting below this cap of dead skin. Though live skin is growing under the cap and above the bone, there is still a perimeter of exposure to infection around the interface between the live and dead skin that maintains my full attention. I also have three-eights of an inch of bone sticking out the end of the toe's new skin line. It should finish sealing up within the next month or so, I hope to god.
Nerve pain is still extreme, though episodes do not last as long, nor involve as much of the tip of my foot. The structural damage to the front foot pad is still extensive, though strength, flexibility, and endurance are increasing as the structural pain stays fairly constant under increasing work loads.
That is excellent progress. As strength increases, my experiences tell me that the pain will eventually receede.
Early necrosis and first separation of live from dead skin.
III: Fourth month.
IV: Sleeping aid.
Peeling skin and separating dead skin.
Toe protection cage used to air it out a little..
At the beginning of September the live skin had grown up to the bone sticking out of my toe. The dead skin capping the exposed bone narrowed down until it was just covering the bone as the new skin grew up to the bone.
Update: Images Coming!
September 5 2011: After an almost six mile jog-walk I washed and sanitized the dead skin/live skin junction at the tip of my toe, as seen above, and was applying antibiotic creme when the dead skin patch broke off. It turns out that the dead skin had completely retreated to the point where it only was covering the bone sticking out of the tip of my toe, as the live skin regrew up to the bone.
The dead skin patch was attached to the tip of my toe bone.
This kind of freaked me out. But upon close inspection of the toe revealed that the bone had broken off below the bottom level of the regrowing skin. Perfect.
September 5 2011: As I inspected the wound and the bone fragment I saw that my body had retained circulation in the toe bone up to the bottom level of the growing skin, and that the bone above that point was denied circulation.
This indicated that the bone was deterioriting as the new skin was growing up to it. The bone broke off at the point in time when the new skin grew up to the dead bone (which was covered with the dead skin), and it broke off at the position which located the new end of my toe bone perfectly, just below the bottom of the new skin.
The timing and location of the toe bone breaking off in conjunction with the skin growth was perfect.
Man, the body is an amazing thing.
September 7, 2011: In two days since the bone covered with dead skin broke off the tip of my toe the skin looks like it has already grown a thin layer over the bone. Amazing. I'm going for a walk up to the top of the ridge to celebrate.
THIS PAGE IS UNDER CONSTRUCTION: STAY TUNED FOR MUCH MORE!
COME ON BACK NOW, 'YA HEAR?
The stretching and flexibility videos on this page were shot while rehabing the frostbite depicted above. This is a real-deal injury recovery program.
NP Annie Skradski of the Martinez Veterans Administration for some of the above pictures, and nine months of the finest care and support I've ever gotten from medical professionals during my whole life.
I've seen a hell of a lot of injuries, but few doctors as good as NP Skradski.
Special Thanks to another Ski, as we Polacks are lovingly know. This particular Ski is my Sis, who's generosity has kept me afloat as I hobble back to health.
And I've got to send out a good word to Cliff Flores, NP at Oakland VA. Cliff has tried to help me keep my knees, back, and hips working correctly for a few years now.