Our year anniversary (My Ankle and I)

A year ago, I decided to be brave and hike Mount Katahdin (see above).  It is a huge mountain in northern Maine in Baxter State Park.  I didn't think I would be able to do it and multiple times wanted to turn around.  Right when I was almost to the top of that hellish mountain, above tree-line with the summit in view, I was pulling myself up over a rock and heard and felt a memorable pop in my ankle.  I immediately sat down and started yelling for my husband.  I took off my boot to make sure no bones were popping out, wrapped my ankle in my bandana, and put my boot back on and tied it as tight as it would go.  When I got up and tried to walk on it it kept popping.  So I had to slide down the entire mountain on my rear.  After crying and cursing my way down the mountain, with my husband having to catch me in the steeper areas, I made it down.  I had a giant hole in the butt of my pants (of course I chose pink underwear that day) and my hands were bruised and scuffed up, but I made it down.

I swore I would never hiked that mountain again.  This weekend, a year after the initial injury, we drove up to Baxter and my husband hiked up Katahdin, but I chose to take a more leisurely hike.  But still I was able to hike!  There were hills and uneven surfaces and even exposed roots I had to navigate around, but I did fine.  It was a great feeling!  Being able to be outdoors again and go places you can only get to by hiking in is a wonderful experience.  I am grateful for that and happy to be doing so well.  Maybe in a year or two when I have a little more confidence in my ankle, I will hike to the top of Katahdin!  Never say never right?

Why no Physical Therapy?

I just realized it has been almost a month since my last post.  Well that is for many good reasons!  First I have been out enjoying the last days of warm weather up here in Maine.  I have kept myself very busy between walks, trips to visits friends, trips home for a wedding, and camping trips.  I consider myself completely healed.  I had to cancel my check up with my doctor, because I had missed work two weeks in a row for my traveling :), so I do not go back until the end of the month.  But everything is doing remarkably well.  I probably will not post much more after this.  I promise to get a picture up of my scar.  I think it looks really good.

So I thought I would spend a bit of time discussing my doctor's reasoning for not making me go through any Physical Therapy.  At a wedding I was at last weekend I was talking to my friend who is a Physical Therapist about my surgery and I admitted how happy I was I didn't have to go through any PT.  So my doctor does not prescribe PT for most of his patients.  For most of the ankle injuries he deals with, he puts you in a cast for 8 weeks and orders to be non-weight bearing.  This 8 weeks allows the injury to heal completely.  Then after the cast is removed, he wants you to walk.  His reasoning for not ordering PT is he says after the cast is removed and you start to walk again, the ankle swells, gets red, and hurts!  Physical Therapists are trained so when they see that, they make the patient slow down and rest and stop whatever they were doing that caused that.  My doctor said that is going to happened, and you have to simply push through it.  He doesn't want the PT to slow down your walking again.  I will be honest, walking again hurt like hell.  It was hard, but I was so happy to walk again so I just did it.  Luckily I also had Vicodin that he prescribed :).  When I told my friend my doctor's reasoning, she seemed offended.  But agreed that she could see his point, and obviously it worked for me.  But she said she could see it not working for many patients who baby it or find it hard to really push themselves, and I do agree with that.  I am not saying PT is bad after this surgery, but this was just my doctor's reasoning.  Honestly, I was happy not to have to go through any PT, its a pain in the ass.  I went through it for over 10 weeks for my ACL repair.  So I was thrilled when I didn't have to go through it again.  Obviously, my doctors method worked for me and works for his patients.

My surgery was on June 21st, 2010.  Today is October 8th, 2010.  You do the math on what week I am on, I tried and stopped.  I am so happy to be walking again and back to normal.  I have been going to the gym and working out again.  Today I am going to swim some laps, which I am very excited about.  If you have to go through this surgery, it sucks, I will be honest.  However, it is worth it.  I am so glad I had it done and it is fixed.

Everyday Gets Better - Week 10 Post Op

I have had a great end to my summer.  Even though I was on bed rest and in a cast for the majority of summer, these last few weeks have been great.  My parents came up for a visit and we rented a camp (for you non-Mainers, that is basically a cabin in the woods or on a lake).  The camp was on a beautiful lake on the blue hill peninsula.  It was a great visit with my parents and made me forget at times about this whole ankle incident.

At times, when I walk my ankle is fine and I walk like a normal person would.  I have even had coworkers comment on it.  However, there are times when it is stiff or sore and I notice a limp.  There isn't much pain in the ankle.  My knee at times can hurt, I think it is just getting use to moving again.  The swelling does get bad.  At work I try to put my leg on my desk when I can, but I have been getting so busy that I usually am unable to elevate it until I come home.  It is really stiff in the morning and when I get up it takes a few steps until I am able to really walk on it, but every morning does get better.

Walking is getting better as well.  Over the weekend I really wasn't able to track my mileage.  But last night I walked 2 miles on a gravel trail and through the woods on an uneven trail.  For me that is huge.  Not the mileage, but the uneven surfaces.  When you walk on uneven surfaces, your ankle stretches and moves in ways it doesn't on flat surfaces.  But I was confident walking there.  My speed when I walk is somewhat normal, I don't walk really slow like I did the first few days.  I am hoping to get up to three or four miles by the end of the week.  I really wish I could swim laps in a pool, by my doctor said not until my next check up. 

The swelling in my ankle is the worst when I come home from work.  Surprisingly, walking does make is swell but not as bad.  When I take my shoes and ankle sock off after walking, my ankle looks so funny.  But I will just elevate it or wrap it up and the swelling eventually goes down.

Everyday does get better.  

Where would I be without Vicodin?

I am still walking!  I did a lot today but am paying for it.  Today I cleaned the house and did some laundry. Surprisingly I actually missed doing that the past eight weeks.  This afternoon I went for a walk.  Instead of driving to the trail I decided to walk.  I also thought Tylenol would suffice for the pain, I was wrong.  I managed to walk about a mile and a half.  I noticed I moved more fluidly if that makes since.  I didn't feel like I was hobbling as much.  However, it started to hurt.  I regretted not taking the Vicodin.  But I called a friend to chit chat and take my mind of the pain.  Before I knew it I was back home and able to elevate my leg with a nice cold ice pack.

After today, I was really grateful that my doctor prescribe more pain meds.  At first I didn't think I would need them.  But it is painful to start walking again.  I could see how the pain could be intimidating and make me want to stop or dread walking again.  So if you reading this and going through the same ordeal, ask for drugs!  The worst thing your doctor can say is no, and perhaps suspect you are a junky.  But seriously, pain meds exist for a reason.  Pain is not good for our bodies.  If I was relying simply on Tylenol to get me out and walking, I could see it slowing me down.  My doctor said the more I walk, the better the pain and swelling will get.  But the pain meds are wonderful at the end of the day and in the morning when it hurts the most and is the hardest to move.

I plan on walking more and more.  I might try getting my walk in during the morning, in hopes that it will be easier than in the afternoon.  I am just grateful to be walking again.

Walking is hard!

The first step out of bed this morning was hard.  I needed to use one crutch just to make it out of my room and down the hall to the bathroom.  I followed the doctors orders and popped a Vicodin.  As my husband said "What a nice way to start the morning".  But honestly, the pain meds worked.  I noticed it helped me walk more naturally and ignore the pain.  The more I walk the better it gets.  When I sit down for a few minutes and try to get up and walk, it is much harder.  But it is sooooo nice to be walking again.

I drove to work this morning.  I have to admit, this is the first I have broken my doctors orders.  He said wait 10 days.  In my defense, my husband is out of town, so it was drive or take a cab.  I also tested things out in the driveway before pulling out on the road.  Driving is easy. 

But when I went to park for work, I purposefully parked far away.  Its a walk from the parking lot to my building anyway, but I wanted to push myself a little more.  I even left my crutches in the car and carried my bookbag and a bag of books to my office!  Then I even walked over to the library on campus to return books, and took the long way back.

When I walk, it is slow, and hurts around my heel.  But the more I walk, it feels like everything is stretching out and learning how to work again.  Its sounds crazy, but I even think my muscle has started to come back.  I walk very slow and try not to limp and to walk as naturally as possible.  Its only 10 am, but at lunch I am going to go for a long walk.  Have I said how nice it is to be walking!!!!!! 

For shoes, I am wearing my chaco sandals.   Chacos are the most amazing sandals ever!  I have around 5 pairs, all different styles and have worn them for years.  The ones I am wearing look like the ones below, only more colorful.  I put a bandage over my incision so it doesn't get irritated.  But these sandals are great to walk in.  Plus they are great for after this surgery because you can adjust the straps with the swelling.  I started to put a tennis shoe on today.  But my poor foot has been imprisoned for 8 long weeks, it wants to breathe!  Plus it was kind of uncomfortable to wear the sneaker.  I started to wrap up my ankle to help with the swelling for today.  But my doctor said it was unnecessary, he said it will swell no matter what I do, and the wrap could prevent my ankle from moving naturally when I walk.  But I do recommend these sandals for after surgery or for anyone.  I love Chacos!

This weekend I plan on running errands, doing a little shopping, and walking more!  My goal: 2 miles by Sunday.  Think I can do it? 

Goodbye Cast and Crutches! I can walk again!

Today went wonderfully!!!  I am walking.

Today I discovered that after having a leg in a cast for 8 weeks it gets kind of gross :).  After they took the cast off and I was waiting to see my doctor, I was appalled by the look of my leg.  My hair had managed to grow an inch long.  Dead skin was all over the place.  The scab from the incision was dark and crusty.  The saddest thing was my skinny leg that was about the size of my arm.  It was gross looking.  But I managed to walk that pathetic looking leg right out of the doctors office!  I even took it to the beach.  Now it is shaved, exfoliated, moisturized, and with a new tan.

My doctor told me everything has healed great.  He wants me to walk as much as possible and said that is the only way things will get better.  He told me it will hurt, get read, swell up, and be hard to do, but not to let that stop me from walking.  He even gave me more pain meds because he said he didn't want the pain to interfere with my walking.  He wants me to stop using the crutches completely in 5 days.  He said I could lose them today if I was comfortable with it.  He told me to walk until it hurts too much.  Take a five minute break, then walk some more!  He also said limping does not count.  I was hoping he would let me swim, but he said not yet.  I am not allowed to soak the incision or use any ointments or lotions around the incision because infection is still a risk.  If I am out in the sun I have to keep it covered so it won't burn.

Walking is weird.  Its not really painful.  In fact, the most pain is at my heel.  My ankle just feels really stiff.  Like it hasn't move in 8 weeks :).  Walking on pavement is easy.  Walking in the grass and gravel is a little harder.  Walking in the sand right now is ridiculously hard.  I left the doctors office with my chacos on and a sock on the bad foot.  They were really easy to get on and off, and they don't bother my incision.  When I walk with the crutches I use more of a natural step.  When I don't, I limp.  Tomorrow and over the weekend I plan on walking alot!  I want this to get better and I want to feel active again.

My incision wound looks really good.  There is still a little scab at the top, but I think it looks great.  Its not as big as I remember it being.  I don't mind scars too much.  In fact, the book "Little Bee" has a great quote about scars.  "Scars are beautiful because they are proof we survived"  I thought that was a great quote to go by.  I will survive this!

4 Weeks Down!

Four weeks ago today I had my surgery.  It is amazing how fast the time has gone.  It is nice to know that four weeks are behind me, but also frustrating to know I still have four more weeks of this.  However, next week I go back in for a new cast and I believe they will release me from this inactive state I am stuck in and will let me to move around more.  I intend on going back to work on August 2nd (2 weeks).  I have a feeling once I start back up at work the remaining 2 weeks will go even faster.

Yesterday I realized how much the internet occupies my days.  The other day I found myself not even being able to close my laptop while watching a movie.  Or sometimes I watch a movie online and surf the internet at the same time.  I hope this surgery doesn't make my brain turn to mush.  The first few weeks I was really good about reading.  I was reading about a book a day.  Now I am reading a book a week.  I find myself checking facebook every 10 minutes and being annoyed that no one has changed their status or added anything of interest.  Ebay has been a good friend.  My recent purchases have been Nintendo games for $2.  TIP: Do not keep your credit card by your bedside when being laid up for a few weeks.  Not good.  I have found that I justify my purchases because I feel bad making my husband go and get things for me, so just order it online of course!  Here is a list of my most frequented websites...

Facebook, Kayak.com, hotmail, gmail (no idea why I have so many emails), cnn.com, netflix, blogger.com, ebay, steepandcheap.com, amazon.com, weather.com. 

My laptop has been a huge lifesaver for this recovery time.  However, I wonder if I would be doing more productive things with my time if I didn't have it.  Maybe I will make a goal tomorrow to only check my computer 5 times, and have a time limit of 10 minutes each time.  I will let you know how it goes.  The video below cracked me up and I felt is very true.

A Day at the Beach!

My cast was already too lose after the second day, so we had to go back to the doctor's office this week to get another cast put on.  The hassle of it all is that my doctor's office is over two hours away!  However, there are many lovely beaches around Portland, and I love the beach, and my husband loves to surf.  There happened to be good waves that day, so we got our stuff together and spent a day at the beach!

We visited Popham Beach, which is my favorite beach in Maine.  They have beach wheelchairs, so my husband was able to push me out to the beach.  I plopped down in a beach chair and my husband used a laundry basket and two pillows to keep my leg elevated.  It was perfect!  It did get a little warm and I was jealous of everyone able to go swimming in the ocean, but it was still wonderful to get out and get some sun and enjoy the beautiful ocean.

After the beach we went to my doctor's office and I got a new cast.  It is much tighter and more of my toes are sticking out now.  I might get adventurous today and give myself a pedicure.  The incision wound still looked good and they said everything looked great.  I have been a little paranoid about getting a blood clot.  I read someone's blog who got a blood clot and have been worried about it since.  I asked the nurse who was putting my cast on what to look for in case I do get one.  She said most people have them and don't realize it.  However, she said she has worked there for over four years and has only seen 2 patients get blood clots.  She said both patients were being noncompliant and were walking on their cast when they were suppose to be non-weight bearing!  Goes to show you how important it is to follow the doctor's orders.

In two weeks I will go back to get a new cast put on, and hopefully they will release me so I will be able to get out of the house more and go back to work!

Also, I have a new tip to share in regards to showering/bathing.  I have started taking baths.  I have found it is really easy to sit on the edge of the tub, then with my back facing the other side of the tub I reach my arms back to the opposite side of the tub and just lower myself in.  Unfortunately, I can't sit back and relax because our tub is facing a wall, therefore I am not able to hang my leg over the right side of the tub.  But it is nice just to be able to do it.  I don't see myself attempting to shower.  The idea of taking a shower with crutches doesn't sound so great, plus I am not very graceful, so I can easily foresee me slipping and falling.  The tub is great though!

3 Weeks Down!!!!

Tomorrow will be 3 weeks or 21 Days (sounds better) since my surgery.  I am still on bed rest, and keep my leg elevated for the majority of the day.  The doctor told me at my last visit that if I keep up the good work and keep it elevated I will be released and will able to go to work and move around more.  I am able to get up and down the stairs much more easily and spend more time downstairs than up somedays.  My toes still turn blue and it becomes painful if I am up on my feet too long, but everyday the pain and swelling is less.  It is amazing how much better the cast feels in comparison to the splint.  It is so much lighter and makes crutching around much easier.  However, my cast is already very loose.  I was told this would happen in a few weeks time.  But I called the day after I got my cast because I could stick my hand down my cast where my calf is (great for itching).  I was afraid it might be too loose and I am terrified of hurting my ankle or getting an infection.  The nurse I spoke with told me to go through the weekend to see how it felt.  She said a loose cast can become irritating to the skin and it can be bad if it rubs against the incision.  So Monday I will probably go down for a new cast which sucks because its a 2+ hour drive.  So we are thinking about going to the beach in the morning since we will be driving all the way down to Portland Maine.  There is a beach with sand wheelchairs and I am thinking if I keep my foot elevated the whole time, the beach and sun will do me good?  I am probably a little deficient in Vitamin D since I have been indoors so much the past 3 weeks.  What do you think?  If we go I will let you know how it goes.

Sometimes I get on these "Poor Me" kicks where I think about how much this sucks.  I will watch my husband walk around the house and be able to do things I cannot because I am on crutches.  But I recently have been thinking about all of the people who cannot walk for the rest of their lives, or who always have to rely on crutches or a cane.  I try to keep that in mind and remember that this is only temporary and in a few weeks I will be walking again and life will go back to normal.  I need to start realizing how fortunate I was to have insurance and to be able to have surgery to fix my problem so that I can be active again.  We just had a friend over who was telling me when he broke his leg he had a cast on his entire leg!  That would suck!

Today is my husbands and my first anniversary!  We were married last year in Camden, Maine.  Because I can't really go anywhere we have decided to stay home and we are going to cook some lobsters and have a nice dinner!  We had a lobster bake for our wedding, so I suggested starting a tradition of having lobster for every anniversary.  :)  Sounds like a wonderful tradition to start!

16 Days Down!

So this begins my 16th day after surgery on my peroneal tendons.  I am doing much better and able to get around the house more.  Tylenol has been sufficient for my pain, and I have become a pro on crutches.  Tomorrow I go in for my first post op appointment.  I will have my staples removed and a new cast put on. I am really looking forward to seeing my incision wound and getting a new cast put on.  This splint it hot and heavy!

I waited until summer to have this surgery done.  It was kind of my only option.  It really sucks though :).  I live in Maine and it has been unseasonably warm.  Perfect weather to go to the beach or go swimming.  But I am stuck indoors which is hot!  So if you can choose when you want to have your surgery, I would do it during a season where you don't mind being inside.

My biggest complaint with my ankle is the swelling.  You really have to keep it elevated or it swells right up.  It feels like it is going to explode sometimes.  If I am on my feet for 5 minutes, it becomes extremely uncomfortable.  I am looking forward to that going away.

One other struggle with this surgery is how you lose your independence.  You really need someone around to help you get a bowl of cereal, or do certain things for you.  Luckily my husband is on break and he is around and very helpful.  But its nice to be able to do a few things by yourself, so here are my newest tips...

-Make sure you have a Nalgene water bottle.  These are easy to fill and you can hold it by the loop with you crutch back to bed or the couch.

-Have popsicles around!  I read this in someone else's blog and it has been a huge help!  It is a sweet treat that you can grab yourself and take with you.  Plus they just taste good.  I recently got Edy's Blueberry with Acai.  They taste really good and have antioxidants, which is important while you heal!

-Use a little backpack or shoulder strap bag.  This way you can take things with you around the house.  It is extremely helpful.

- Here is a picture of my splint.  Really looking forward to a cast.  You can see the foam pillow the hospital gave me.  It has been a lifesaver.  During the day I put another pillow on top to get more elevation.  If you doctor doesn't give you one of these, I recommend going out and finding something similar.  My leg never falls out while I am sleeping and I get more elevation than using a stack of bed pillows!

Other Great Blogs...

I have found some other great blogs from people who have shared the same experiences with their peroneal tendon surgery.  I like these blogs because they are positive and won't scare you about having this surgery!

http://thesabins.com/category/the-trouble-with-tendons/

www.dreamingfullcircle.com

http://peronealtendonsurgeryblog.blogspot.com/

http://www.runnersworld.com/community/forums/injury-prevention/injuries/just-surgery-peroneal-tendon/.0
- This one is great because it shares many stories.

If I find others I will share them!

Post Surgery Tips

Day 1 - Not too bad. Took my Percocet religiously and kept my foot elevated. The hospital gave me this big pillow that my leg sits in. Its amazing how much better it feels when it is elevated. The nerve blocker wore off so the pain increased. I iced behind my knee which helped a lot. TIP: use the ice packs made to go in coolers, the rectangular shaped ones. They stay cold really long and fit perfectly behind the knee. Ice really helps with the pain.

Day 2 - Pain a little worse. Perfected going to the bathroom with only one leg :). Also managed to make the bed. These little things mean so much!

Day 3 - Tried to ease up on the Percocet a bit. Tylenol and ice worked well during the day. (My doctor said no IB Prophen because it prevents healing) The pain seems to be the worse in the evening. TIP: Try to save your Percocet for night, especially when you sleep! I went ahead and asked the doctor for more pain meds, I think it will be something less strong.

Day 4 - Feeling a lot better. Figured out a way to take a weird bath. I had surgery on my right leg. So I was trying to figure out how I could shower. It is really important not to get the cast wet to prevent infection. So I folded a towel in half length wise and laid it on the edge of the tub. I ran water in the tub with soap. Then I sat on the edge of the tub with my bad leg propped up on the edge with a towel over it and the other leg in the tub. Then I used a washcloth and bathed myself. It felt really good after I was done and was easy. I did it all by myself too! Now my big dilemma is whether I should take the time to shave my one good leg or just let it go :). I am hoping to get downstairs either today or tomorrow. I have been stuck upstairs since Monday, really wishing we had a toilet downstairs!

Other Tips... I read that Vitamin C is good for healing so I have been taking that. Also, elevation seems to be so important. It really feels better when it is elevated. When I have to get up it, I feel more pressure around my ankle instantly. Also make sure you have someone around to take care of you. I am lucking to have had my husband around. You can't cook, get water, do anything! The first two weeks are the most important to have someone around. My husband Dan has been so wonderful and helpful!

Surgery Day!

My surgery took place at Mercy Hospital in Portland, Maine. My doctor was Dr. Pomeroy. I was really impressed with the hospital facilities and all of the staff there. Everyone was so nice, and everything went very smoothly. My surgery was scheduled for 2:15, so I had to be at the hospital at 12:15. I signed in and was taken back. They immediately had me change and get in bed while they started an IV and began to get me ready. The anesthesiologist came back to discuss what he was going to do. He gave me a nerve blocker in the back of my knee and put me completely out during surgery. Prior to surgery the OR nurse came and spoke with me. I had my contacts out but my glasses on. She let me keep them on in the OR and took them off after introducing me to everyone in the OR. I am blind without my glasses so its nice that they were thoughtful about that. I woke up after surgery in the recovery room with a giant Splint/Cast on my leg. The nurse put my glasses on and gave me some ice. I started to wake up and they gave me crackers and juice. It was about 3:00 and I wasn't allowed to eat all day so the crackers were awesome!

I reacted well to the anesthesia and felt fine after surgery. I wasn't in any pain at all. By 4:00 I was dressed and ready to go home! I had no idea I would feel that fine and be that coherent. I was able to talk on the phone with my sister and mom and even my husband was in shock I was doing so well.

We made it home and picked up some Thai food for dinner. I then made my way upstairs. This was interesting. The best way to get upstairs for the first time for me was to sit on my butt on the stairs, and push myself up each step with my arms and one leg while my husband was holding my leg with the cast. I took my Percocet and was out and slept great! I made sure to set my alarm in the middle of the night to wake up when it was time for me to take more Percocet.

A Few Tips Prior to Surgery

My Surgery was on Monday June 21st. Here are some pre-surgery tips I can give that made my experience a little easier...

1- Make a list of things you want to do before surgery, remember you won't be able to walk on two legs for about 8 weeks.

2- Lay out clothes to wear for at least one week after surgery.

- This has been very helpful. My husband has had to do EVERYTHING for me. So I appreciate anything I can do by myself. Getting dressed is one of them. On my dresser I have a stack of comfortable clothes, including underwear. This way I can pick out what I want to wear and get dressed by myself.

3- Get your room (or wherever you plan on being for the majority of the time) ready and stocked.

- For me this was our bedroom. We only have one bathroom and it is upstairs (16 stairs to be exact). So I made our bedroom my hangout spot. I stocked up on plenty of library books, which are all in a giant llbean bag next to my bed. I also plugged the phone charger and macbook charger right next to the bed. I brought up the DVD player and got a TV for the bedroom. I also have all of my medicine, vitamins, and most importantly PAIN PILLS! on my bedstand.

4- Join Netflix and Pick out some good books!

- We were already Netflix members, but movies do kill a lot of time. I also made a list of books I have been waiting to read and got them from the library.

5- The day before your surgery RELAX!

- I was a little anxious right before my surgery. So we spent the day at the beach and it was perfect!

So I decided to start a blog...

Back in October of 2009, I busted my retinaculum ligament which holds your peroneal tendon in place (see picture). Basically my tendon was rolling over my ankle bone, which wasn't the most comfortable thing in the world. I kept avoiding going to the doctor at first thinking it was just a sprain, and then finally being a little scared to go to the doctor knowing surgery was more than likely the only solution. I finally got the courage to go to the doctor and was referred to a specialist at the New England Foot and Ankle Specialists down in Portland, Maine. I was told surgery was needed and that I would be in a cast for about 6-8 weeks!

So I decided to blog about my experience with this. It was hard to find information on the web about this surgery. I found some personal experiences from other who have had to go through this, but their experiences were so negative and awful sounding that it really scared the shit out of me. So I have decided to write this blog in a positive fashion and provide tips for those who have to go through it and to allow people a little laugh at some of the things I have to deal with for the next 6-8 weeks.