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ESWT post surgical heel spur surgery.

Posted by Dr. Zuckermand on 5/11/01 at 09:17 (047442)

I am exminating another ESWT interesting case at least for Dr. Z

She had heel spur surgery with pf release done Dec 1999. Alot of pain non relief then ESWT done right heel on april 25,2000. She told me that she is completely pain free and no pain at all right foot. She is now here for extreme pain in her other foot. Can't believe that she waited two months for treatment with the other foot. I am entering her into the data base. Interesting again she tells me pain free. My hands on examination shows no decrease range of motion left foot and ankle. There is no pain at all on deep palpation. Only received a 9 rating for the treatment.

If any ESWT docs have some post ESWT results for poor pain relief after heel spur surgery please post here. I am looking to do a paper on results of ESWT after failed foot surgery. I am looking for twenty cases. I have about 10-'15. I find it a very interesting subject.

Re: ESWT post surgical heel spur surgery.

Pauline on 5/11/01 at 10:15 (047452)

Dr.Z,
I've been reading some articles that seemed to indicate that even after pf release the part of the pf that is tucked in near the insertion point may still be a cause for pain. Perhaps when patients are then treated with ESWT as you are doing the ESWT is able to bring about heeling where the release didn't reach. The abstracts related to continual cause for pain in some patients after pf release surgery.

We have a lot of people posting about pain after pf release surgery. I think the postings are only the tip of the iceburg. It's an area that interests me and certainly worth the researcher's study.

Re: ESWT post surgical heel spur surgery.

Sherrie M. on 5/11/01 at 12:58 (047487)

Hi Dr.Z, Great news, I hope I turn out to be one of your success stories! I was talking to a friend of mine who just married a message therapist and he is suggesting that I let her evaluate me to see if she could do deep message or is that the same a myofacial release therapy ( Im' not sure) I thought I read that you were working with a message therapist that was doing some deep message on one of your patients that didn't receive that much benefits from the ESWT treatment? Am I wrong? Just thought I'd ask and get your thoughts, thanks Sherrie

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 14:12 (047500)

It is my opinion that the release at the insertion works only became you are injurying the site that isn't healing and then allows the healing process to kicks in.

I feel that the EPF release since it isn't released at the pf insertion stops the pulling at the fascia and thus is resting the area that is not healing. ESWT is done at the inserion and is directing the treatment at the injuried area.

So there is a chance after the EPF for the area at the insertion not to heal with a result that the pain at the insertion is still there.

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 14:13 (047501)

I believe that Kay S is doing active release therapy after failed ESWT treatment by Dr. Z

Re: ESWT post surgical heel spur surgery.

Pauline on 5/11/01 at 14:53 (047504)

It would be wonderful to know why ESWT works for some and not for others.
Are there any theories on this. Are there any similarities to look for that could pin point these patients ahead of time?

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 15:20 (047507)

I have a theory that I can't prove yet.
1. Missed the focal point.

2. Need more treatment then the single one shot treatment. Just a gut feeling
3. Too much tissue damage???

I will kept thinking about this. At one time John W and I had alot of discussions about this. His feeling was that the problem was a type of bone necrosis. I then told him about Dr. Smith from California and his paper

Dr. Smith of California ( uses the ossatron) wrote an article in 1992 that talks about fractures in the heel itself. He staged different types of stress fractures. I would think that a bone scan and or mri would pick these up. His treatment was screw fixation . bone stimulator, drilling holes into the calcaneus. Very small group of patiens claimed very good results.

Re: ESWT post surgical heel spur surgery.

Julie on 5/11/01 at 16:40 (047513)

Could it have something to do with the fact that some people heal faster/better than others - and could this have something to do with circulation?

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 18:00 (047520)

Yes yes. I am trying to figure out why it does work in the healthly patients that do have healthy ciriculation and have no history of healing problems. That is another list that you can determine before the treatment

Re: ESWT post surgical heel spur surgery.

Dr. Marlene Reid on 5/11/01 at 20:36 (047539)

I think that failure of surgical release is more due to the failure to release the section that is tight/inflammed completely. The medical band is actually VERY medial and usually doesn't get released with EPF. People with very medial pain would need to be opened up more, if surgery is the option they choose. We've done a lot of cadaveric dissections of heel and the medial band wraps around the medial muscle belly. Most people are actually releasing the medial aspect of the central band.

Re: ESWT post surgical heel spur surgery.

john h on 5/12/01 at 09:25 (047574)

my thought is the very narrow direct shockwave is not hitting the correct spot. or there is someother underlying problem.

Re: ESWT post surgical heel spur surgery.

JudyS on 5/12/01 at 11:13 (047589)

Dr. Reid, at the risk of sounding PF ignorant (even after 3 years....), what does 'medial' mean in this case? And, why doesn't EPF reach it?

Re: ESWT post surgical heel spur surgery.

Kay S on 5/12/01 at 14:02 (047598)

I cringed when I read my name linked with 'failed ESWT'! I don't know that it exactly failed, and I am still thinking about trying again. Yes, I am doing the ART now, but let's face it, I have a LONG history of this, and after the very first treatment, I did think I was better. The second I can't say I noticed any improvement. Maybe I just respond to the odd number of treatments?
I have had numerous surgeries, never have had any problem with healing, and have had all the various circulation tests that one could have, and they all turn out normal. I have been worked up for everything possible since having cancer 3 years ago, so it's not like I have some chronic illness that is being missed by all the doctors I see. (no problem with the cancer anymore either)
I guess I am just weird, have a stubborn case, and will have to grit my teeth and continue to try to find some relief, however it may come!
The ART is helping some, but I don't walk out of there thinking I am anywhere close to being cured. I still have pain every day, especially after being on my feet awhile.
I am planning to have another ESWT in the future, though I haven't decided when I'll do that yet.
Please don't give up on me, Dr. Z! Keep trying to think of new ways to help me. I don't want to be in that low percentage of people who aren't helped by ESWT. I don't want to be in the failed group! I want to be with my friends who get better........
Kay

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/12/01 at 14:25 (047601)

I will never give up I have alot of ideas left in the old foot doctor bag of tricks

Re: ESWT post surgical heel spur surgery.

Dr. Marlene Reid on 5/12/01 at 21:10 (047618)

Medial is the inside most portion. In the case of the medial band, it is unlikely that EPF reaches all of it because it curves around the muscles and isn't flat as the rest of the fascia is.

Re: ESWT post surgical heel spur surgery.

Pauline on 5/12/01 at 21:56 (047620)

For surgery is the foot entered on the medial side?

Re: ESWT post surgical heel spur surgery.

DeniseA on 5/13/01 at hrmin (047632)

Hey Kay,

Dr. Zuckerman give up? You haven't seen this man when he has a challenge. That my dear is the LAST of your worries. This guy hates it when someone is left unresolved. Have faith kiddo. Hang in there.

Denise

Re: ESWT post surgical heel spur surgery.

Nancy N on 5/13/01 at 09:40 (047636)

Kay--

Don't forget, you could join us in Woodbury on June 15!

Re: ESWT post surgical heel spur surgery.

Kay S on 5/13/01 at 13:47 (047648)

Thanks, Denise. I needed that!
Kay

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/13/01 at 17:36 (047663)

I use the plantar side but alot of doctors use the medial side of the foot. EPF is the side , Open tradional is the side . MIS side but I teach the bottom.

Re: ESWT post surgical heel spur surgery.

john h on 5/14/01 at 09:41 (047706)

was it the little blue train that said 'i think i can, i think ican' or was it 'i know i can, i know i can'?

Re: ESWT post surgical heel spur surgery.

john h on 5/15/01 at 08:41 (047787)

dr baxter suggest the pain generator in many or most pf cases is the baxter nerve under the fascia. if the pf release was not over that nerve then there would not be a good result or if the ESWT were not on the inflamed fascia at the point over the nerve there would not be a could result. all this of course is under the presumption that dr baxter's theory of the pain generator is correct.

Re: ESWT post surgical heel spur surgery.

Pauline on 5/11/01 at 10:15 (047452)

Dr.Z,
I've been reading some articles that seemed to indicate that even after pf release the part of the pf that is tucked in near the insertion point may still be a cause for pain. Perhaps when patients are then treated with ESWT as you are doing the ESWT is able to bring about heeling where the release didn't reach. The abstracts related to continual cause for pain in some patients after pf release surgery.

We have a lot of people posting about pain after pf release surgery. I think the postings are only the tip of the iceburg. It's an area that interests me and certainly worth the researcher's study.

Re: ESWT post surgical heel spur surgery.

Sherrie M. on 5/11/01 at 12:58 (047487)

Hi Dr.Z, Great news, I hope I turn out to be one of your success stories! I was talking to a friend of mine who just married a message therapist and he is suggesting that I let her evaluate me to see if she could do deep message or is that the same a myofacial release therapy ( Im' not sure) I thought I read that you were working with a message therapist that was doing some deep message on one of your patients that didn't receive that much benefits from the ESWT treatment? Am I wrong? Just thought I'd ask and get your thoughts, thanks Sherrie

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 14:12 (047500)

It is my opinion that the release at the insertion works only became you are injurying the site that isn't healing and then allows the healing process to kicks in.

I feel that the EPF release since it isn't released at the pf insertion stops the pulling at the fascia and thus is resting the area that is not healing. ESWT is done at the inserion and is directing the treatment at the injuried area.

So there is a chance after the EPF for the area at the insertion not to heal with a result that the pain at the insertion is still there.

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 14:13 (047501)

I believe that Kay S is doing active release therapy after failed ESWT treatment by Dr. Z

Re: ESWT post surgical heel spur surgery.

Pauline on 5/11/01 at 14:53 (047504)

It would be wonderful to know why ESWT works for some and not for others.
Are there any theories on this. Are there any similarities to look for that could pin point these patients ahead of time?

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 15:20 (047507)

I have a theory that I can't prove yet.
1. Missed the focal point.

2. Need more treatment then the single one shot treatment. Just a gut feeling
3. Too much tissue damage???

I will kept thinking about this. At one time John W and I had alot of discussions about this. His feeling was that the problem was a type of bone necrosis. I then told him about Dr. Smith from California and his paper

Dr. Smith of California ( uses the ossatron) wrote an article in 1992 that talks about fractures in the heel itself. He staged different types of stress fractures. I would think that a bone scan and or mri would pick these up. His treatment was screw fixation . bone stimulator, drilling holes into the calcaneus. Very small group of patiens claimed very good results.

Re: ESWT post surgical heel spur surgery.

Julie on 5/11/01 at 16:40 (047513)

Could it have something to do with the fact that some people heal faster/better than others - and could this have something to do with circulation?

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/11/01 at 18:00 (047520)

Yes yes. I am trying to figure out why it does work in the healthly patients that do have healthy ciriculation and have no history of healing problems. That is another list that you can determine before the treatment

Re: ESWT post surgical heel spur surgery.

Dr. Marlene Reid on 5/11/01 at 20:36 (047539)

I think that failure of surgical release is more due to the failure to release the section that is tight/inflammed completely. The medical band is actually VERY medial and usually doesn't get released with EPF. People with very medial pain would need to be opened up more, if surgery is the option they choose. We've done a lot of cadaveric dissections of heel and the medial band wraps around the medial muscle belly. Most people are actually releasing the medial aspect of the central band.

Re: ESWT post surgical heel spur surgery.

john h on 5/12/01 at 09:25 (047574)

my thought is the very narrow direct shockwave is not hitting the correct spot. or there is someother underlying problem.

Re: ESWT post surgical heel spur surgery.

JudyS on 5/12/01 at 11:13 (047589)

Dr. Reid, at the risk of sounding PF ignorant (even after 3 years....), what does 'medial' mean in this case? And, why doesn't EPF reach it?

Re: ESWT post surgical heel spur surgery.

Kay S on 5/12/01 at 14:02 (047598)

I cringed when I read my name linked with 'failed ESWT'! I don't know that it exactly failed, and I am still thinking about trying again. Yes, I am doing the ART now, but let's face it, I have a LONG history of this, and after the very first treatment, I did think I was better. The second I can't say I noticed any improvement. Maybe I just respond to the odd number of treatments?
I have had numerous surgeries, never have had any problem with healing, and have had all the various circulation tests that one could have, and they all turn out normal. I have been worked up for everything possible since having cancer 3 years ago, so it's not like I have some chronic illness that is being missed by all the doctors I see. (no problem with the cancer anymore either)
I guess I am just weird, have a stubborn case, and will have to grit my teeth and continue to try to find some relief, however it may come!
The ART is helping some, but I don't walk out of there thinking I am anywhere close to being cured. I still have pain every day, especially after being on my feet awhile.
I am planning to have another ESWT in the future, though I haven't decided when I'll do that yet.
Please don't give up on me, Dr. Z! Keep trying to think of new ways to help me. I don't want to be in that low percentage of people who aren't helped by ESWT. I don't want to be in the failed group! I want to be with my friends who get better........
Kay

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/12/01 at 14:25 (047601)

I will never give up I have alot of ideas left in the old foot doctor bag of tricks

Re: ESWT post surgical heel spur surgery.

Dr. Marlene Reid on 5/12/01 at 21:10 (047618)

Medial is the inside most portion. In the case of the medial band, it is unlikely that EPF reaches all of it because it curves around the muscles and isn't flat as the rest of the fascia is.

Re: ESWT post surgical heel spur surgery.

Pauline on 5/12/01 at 21:56 (047620)

For surgery is the foot entered on the medial side?

Re: ESWT post surgical heel spur surgery.

DeniseA on 5/13/01 at hrmin (047632)

Hey Kay,

Dr. Zuckerman give up? You haven't seen this man when he has a challenge. That my dear is the LAST of your worries. This guy hates it when someone is left unresolved. Have faith kiddo. Hang in there.

Denise

Re: ESWT post surgical heel spur surgery.

Nancy N on 5/13/01 at 09:40 (047636)

Kay--

Don't forget, you could join us in Woodbury on June 15!

Re: ESWT post surgical heel spur surgery.

Kay S on 5/13/01 at 13:47 (047648)

Thanks, Denise. I needed that!
Kay

Re: ESWT post surgical heel spur surgery.

Dr. Zuckerman on 5/13/01 at 17:36 (047663)

I use the plantar side but alot of doctors use the medial side of the foot. EPF is the side , Open tradional is the side . MIS side but I teach the bottom.

Re: ESWT post surgical heel spur surgery.

john h on 5/14/01 at 09:41 (047706)

was it the little blue train that said 'i think i can, i think ican' or was it 'i know i can, i know i can'?

Re: ESWT post surgical heel spur surgery.

john h on 5/15/01 at 08:41 (047787)

dr baxter suggest the pain generator in many or most pf cases is the baxter nerve under the fascia. if the pf release was not over that nerve then there would not be a good result or if the ESWT were not on the inflamed fascia at the point over the nerve there would not be a could result. all this of course is under the presumption that dr baxter's theory of the pain generator is correct.