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Just need some input on surgery...

Posted by Paula G. on 7/30/01 at hrmin (054823)

I had a doctor's appointment today. I have had PF in both feet for almost two years now. I have done every treatment known to man with no results.
So, my orthopedist who does not do the surgery, referred me to one of his partners who does.
I get a bone scan next week to make sure there are no fractures. Then I will meet with him again to discuss the surgery. Is there any pertinent information I need to have???
I feel this is the way to go for me. I have exhausted everything else. He said he makes the incision on the SIDE of the foot? I always thought it was right at the heel. I realize it will take months to notice results, but he sounds very positive.
Are you on crutches with this surgery? Is there a general idea, if so, about how long?
He said something about a partial release? What are the benefits of that? Will that help? He says it may save damage to the other part of the foot?
ANyone with answers or ideas, please let me know. I am desperate for knowledge. That is my only power over this.
I posted on the other board, but wanted to post here too, I hope that is ok.

Re: Just need some input on surgery...

Andrea R. on 7/30/01 at 14:13 (054830)

Paula,

My incision is on the side of my foot. I had a 3/4 release, heel spur removal, and release of pressure on the nerves.

Whether or not you are on crutches seems to depend on the doctor. I had no cast of any sort and was non-weight bearing for 2 and 1/2 weeks. My doctor had me go at my own pace to get rid of the crutches. I kept putting a little more weight on the bad foot and made my first trials without crutches around the house. I kept them in my car just in case and used a cane for a while.

I had my surgery in the middle of May. I can now go grocery shopping, quick trips to the mall and I even mowed part of the lawn yesterday. There is still some pain after use but ice and rest still help.

Make sure he tells you what to expect after surgery. Crutches, cast, weight bearing, etc. My doctor said up to a year for full recovery if surgery is completely successful.

Also, get a handicap tag for your car. It cuts down on alot of extra walking.

Best of luck,

Andrea

Re: Just need some input on surgery...

Ed Davis, DPM on 7/30/01 at hrmin (054857)

You stated that you had 'every treatment known to man' done but please list the treatments and compare them to those listed on the site..there are quite a few. Have you had ESWT? If not, please read the discussions on that---it has virtually no side effects and may have a higher success rate than surgery.

There are a number of different surgical approaches available and thus different incisions used. Some surgeons feel it is better to cut the medial 2/3 to 3/4 of the fascia and others cut the entire fascia.

I use the minimal incision approach which involves making a small incision on the bottom of the heel, about 3mm, and release the entire fascia. It requires only one stitch to close. I like that technique because it is the least traumatic, that is, the least likely to damage adjacent structures.
Every surgeon's experience is different so they will choose the technique they feel works best for them.

Two questions that should be asked: 1) What is the success rate? 2) If not successful, then what is the next treatment plan?
Ed

Re: Just need some input on surgery...

Dr. Zuckerman on 7/30/01 at 19:31 (054859)

Hey Ed

That is the same approach that I use. I don't cut the entire fascia . I cut enought to release the band to get to the spur and then I either rasp or scoop out the bone. It takes about five minutes to do and is very effective. I still would suggest ESWT first. No major complications or nerve damage risk

Re: Just need some input on surgery...

Laura on 7/30/01 at 20:22 (054865)

Paula,
I had this surgery done 3 years ago and it was the biggest mistake I have ever made. I was on crutches 6 weeks, with 10 weeks of physical therapy. I developed scar tissue and have no feeling in the bottom of my foot, but yet I have pain all the time. I have had MRI's and a Cat Scan and EMG tests done, only to tell me that they can't even see the inside of my foot because of all the scar tissue. The pain that I have now is far worse than what it was before, just a different kind of pain. I developed hammertoes for which I am having surgery on in 5 weeks. My doctor didn't mention that I could develop problems like I have nor did I know to ask. Please be sure that you have done absolutely everything else possible before you have surgery. Good Luck, Laura

Re: Excuse me for this ? But what do u call the kind of surgery on the inside of ankle to release pf?

Tammie on 7/31/01 at 08:55 (054926)

I thought that was a minamal incision to? I am sorry I am a bit confused to or is that just the same thing? To many names for thease things confusing for me definetly I am trying to learn tho. I understood there to be maybe 3 ways they do this, open, that epf? I think and the minimal?U know I had this done 15 weeks ago and still not sure what procedure it was I guess I should find out just to satisfy my curiousity> I thought it was minimal as was on inside ankle and some little thing on heel ,am I mistaken? Thank u !

Re: Here's my 2 cents

BrianG on 7/31/01 at 09:41 (054938)

Hi Paula,

I think it's important to find out exactlly how much of the fascia your doc will be cutting. If they don't cut enough, you might as well not have the procedure. I believe this is what happened to me, I had the EPF, and not enough fascia was cut. I did not improve, not even a little bit.

You might also want to ask your doctor for references of people he has helped lately. Don't just take his word for it that 'he has excellent results' or 'heals 80% of his patients'. There is no one out there to justify those numbers, I have found they are meaningless. I do wish there was someone, an agency, keeping track of failures and success's. Until that happens, they can spout off any numbers they want.

Do your research, and you'll have the best chance for a cure. Good luck

BCG

Re: Excuse me for this ? But what do u call the kind of surgery on the inside of ankle to release pf?

Dr. Zuckerman on 7/31/01 at 11:00 (054957)

It is called miminial incision foot surgery on the inside of your foot, or the medial aspect of the heel. I just do it on the bottom cause no nerves or blood vessels there and much easy to get to the bottom of the heel

Re: Here's my 2 cents

Dr. Zuckerman on 7/31/01 at 11:03 (054959)

The amount of fascia cut in my opinion is determined by the physical exmination and comparison of tension in the opposite foot. Each and every patient is different so the doctor needs to understand that you don't cut 1/3 1/4 or whatever. I actually will hear the release and feel the release . This is the only way to truely determine if enough of the release was done in the first place. Just cutting and hoping that you have had enought of the release just won't work. I have done mis releases for a very long time and the sucess depends on the ability to hear and feel the release not to see the release.

Re: Re:Thank u Dr. Z

tammie on 7/31/01 at 11:15 (054961)

Hmm ok I guess that is essier for this little closed mind to comprehend lol! Thanks have a great day and hope u dont get to many stinky feet lolI always think of that , !

Re: Just need some input on surgery...

Ed Davis, DPM on 7/31/01 at hrmin (054965)

Laura:

I agree that all conservative modalities should TRULY be exhausted before surgery. A lot of people are under the belief that 'everything' has been tried but if you look closer, there was really a lot that was not done. It is not just how many things were tried but having the right things done at the right time.

A plantar fascia release generally does not lead to hammertoes. There is a procedure called a 'Steindler stripping' in which the fascia and a layer of muscles, intrinsic muscles, are stripped from the heel bone. The intrinsic muscles are small muscles within the foot which help to stabilize the foot and toe joints. Any possibility that that was what you had done?
Ed

Re: Here's my 2 cents

Ed Davis, DPM on 7/31/01 at hrmin (054969)

The decision on how much of the fascia to cut usually involves the lateral aspect of the fascia. Almost everyone agrees that the medial aspect of the fascia is to be released, the thickest part and the part with the majority of the tension. Some feel that a portion needs to be left laterally in order to help support the calcaneo-cuboid joint.

I am not particularly enthusiastic about EPF. It is a 'high tech' way to do the procedure and unfortunatley, sometimes a way to 'sell' the procedure. I am familiar with some cases in which EPF did not get 'all' the medial fibers.

Both Dr. Z and myself favor a plantar MIS approach though I occasionally do the procedures via the traditional 'open' approach.
Ed

Re: Just need some input on surgery...

laura on 7/31/01 at hrmin (054980)

Dr. Davis, I did have a plantar fasciotomy with 1/2 inch of the plantar fascia removed. I have no feeling from the incision point(instep) to my toes. I no longer have any heel pain so I guess that part actually worked. After having tests done, it was determined that my loss of feeling is being caused by the scar tissue. (that is all that shows up on an MRI) My big toe is straight and will not bend on its own, but my four other toes have become hammertoes, and will not bend at all. I still have feeling on the inside of my foot, if I step on something even as small as a pebble the pain is excrutiating. I work on my feet and after just an hour the pain gets to be unbearable but I have learned to deal with it as my doctor doesn't think that there is anything that can be done for it. Laura

Re: Just need some input on surgery...

SueD on 8/01/01 at hrmin (055052)

I had PF surgery with the inside heel small incision (3/4 release)in April of 1999. It took about nine months for my foot to be totally and completely painfree as it remains today. I would highly recommend the surgery.

Re: Here's my 2 cents

BrianG on 8/01/01 at 09:59 (055058)

Hi Dr. Davis / Dr. Z,

Even though my EPF was a failure, I feel I was at least lucky enough to heal back to where I was before the surgery. I did have some additional arch pain, but that can come with any release procedure, correct? What I'm wondering is, about the EPF. I was told that it was designed so that no nerves or arteries would be hit during the procedure. Do you think this is correct. I've run into quite a few people that the EPF did not work for, but most of us don't seem to run into the complications that other people get from the 'open' types of release.

BCG

Re: Here's my 2 cents

Ed Davis, DPM on 8/01/01 at hrmin (055115)

It can be a hard call. Seems that EPF is potentially less traumatic than the open procedure, particularly the single portal version (uses only one medial incision as opposed to the medial and lateral incisions with the original two portal method).
Ed

Re: Here's my 2 cents

john h on 8/04/01 at 12:01 (055458)

after reading many medical articles and many post from those who have had the procedure through the scope i would elect not to have this procedure done on me (patients view point). a couple of the larger Podiatrist groups in our city have dropped the procedure in favor of MIS.

Re: Here's my 2 cents

Dr. Zuckerman on 8/04/01 at 12:53 (055463)

I have been using the Mis Bottom approach since 1980. I can thank a Dr. Harvy Pilsner for this idea. I was at a convention and we were in a very boring lecture. He was sitting next to me and pulls out polariod pictures out of pocket. No one was sitting next to him, for some reason I did. I had met him years ago. He is from West Virginia. He starts to show me these pictures. and telling me about the great results. Well I start to think and then I started to actually remove the spur and cut the pf from the bottom. I had done it open before before all patients were placed into a cast. There is no question in my mind that this is the best surgical procedure for insertional pf with or without spur . It is very important to also remove some of if not all of the spur and not just cut the pf.

The EPF cuts the pf not at the level of the bone but much move distal and therefore move nerves and arteries to damage. Harvey is either in his mid 80's or not alive today. We owe him alot for this procedure.

Re: Here's my 2 cents

john h on 8/06/01 at 15:32 (055668)

dr z: what protocol do you have your patients follow after a mis PF?

Re: Here's my 2 cents

Dr. Zuckerman on 8/06/01 at 16:32 (055679)

We apply unna boot casting. We soak the foot in acetic acid soaks.
No bare feet. Gradual weight bearing . I see the patient within the first week. Some will need crutches or cane . Some can go back into stiff shoe within two. weeks. If they can't place weight on the foot . We do non-weight bearing stretching. Some patients if they have pain after one week and are limping are placed in a slipper cast. I like patients to walk but I don't want them walking thru the pain.

Re: Just need some input on surgery...

Andrea R. on 7/30/01 at 14:13 (054830)

Paula,

My incision is on the side of my foot. I had a 3/4 release, heel spur removal, and release of pressure on the nerves.

Whether or not you are on crutches seems to depend on the doctor. I had no cast of any sort and was non-weight bearing for 2 and 1/2 weeks. My doctor had me go at my own pace to get rid of the crutches. I kept putting a little more weight on the bad foot and made my first trials without crutches around the house. I kept them in my car just in case and used a cane for a while.

I had my surgery in the middle of May. I can now go grocery shopping, quick trips to the mall and I even mowed part of the lawn yesterday. There is still some pain after use but ice and rest still help.

Make sure he tells you what to expect after surgery. Crutches, cast, weight bearing, etc. My doctor said up to a year for full recovery if surgery is completely successful.

Also, get a handicap tag for your car. It cuts down on alot of extra walking.

Best of luck,

Andrea

Re: Just need some input on surgery...

Ed Davis, DPM on 7/30/01 at hrmin (054857)

You stated that you had 'every treatment known to man' done but please list the treatments and compare them to those listed on the site..there are quite a few. Have you had ESWT? If not, please read the discussions on that---it has virtually no side effects and may have a higher success rate than surgery.

There are a number of different surgical approaches available and thus different incisions used. Some surgeons feel it is better to cut the medial 2/3 to 3/4 of the fascia and others cut the entire fascia.

I use the minimal incision approach which involves making a small incision on the bottom of the heel, about 3mm, and release the entire fascia. It requires only one stitch to close. I like that technique because it is the least traumatic, that is, the least likely to damage adjacent structures.
Every surgeon's experience is different so they will choose the technique they feel works best for them.

Two questions that should be asked: 1) What is the success rate? 2) If not successful, then what is the next treatment plan?
Ed

Re: Just need some input on surgery...

Dr. Zuckerman on 7/30/01 at 19:31 (054859)

Hey Ed

That is the same approach that I use. I don't cut the entire fascia . I cut enought to release the band to get to the spur and then I either rasp or scoop out the bone. It takes about five minutes to do and is very effective. I still would suggest ESWT first. No major complications or nerve damage risk

Re: Just need some input on surgery...

Laura on 7/30/01 at 20:22 (054865)

Paula,
I had this surgery done 3 years ago and it was the biggest mistake I have ever made. I was on crutches 6 weeks, with 10 weeks of physical therapy. I developed scar tissue and have no feeling in the bottom of my foot, but yet I have pain all the time. I have had MRI's and a Cat Scan and EMG tests done, only to tell me that they can't even see the inside of my foot because of all the scar tissue. The pain that I have now is far worse than what it was before, just a different kind of pain. I developed hammertoes for which I am having surgery on in 5 weeks. My doctor didn't mention that I could develop problems like I have nor did I know to ask. Please be sure that you have done absolutely everything else possible before you have surgery. Good Luck, Laura

Re: Excuse me for this ? But what do u call the kind of surgery on the inside of ankle to release pf?

Tammie on 7/31/01 at 08:55 (054926)

I thought that was a minamal incision to? I am sorry I am a bit confused to or is that just the same thing? To many names for thease things confusing for me definetly I am trying to learn tho. I understood there to be maybe 3 ways they do this, open, that epf? I think and the minimal?U know I had this done 15 weeks ago and still not sure what procedure it was I guess I should find out just to satisfy my curiousity> I thought it was minimal as was on inside ankle and some little thing on heel ,am I mistaken? Thank u !

Re: Here's my 2 cents

BrianG on 7/31/01 at 09:41 (054938)

Hi Paula,

I think it's important to find out exactlly how much of the fascia your doc will be cutting. If they don't cut enough, you might as well not have the procedure. I believe this is what happened to me, I had the EPF, and not enough fascia was cut. I did not improve, not even a little bit.

You might also want to ask your doctor for references of people he has helped lately. Don't just take his word for it that 'he has excellent results' or 'heals 80% of his patients'. There is no one out there to justify those numbers, I have found they are meaningless. I do wish there was someone, an agency, keeping track of failures and success's. Until that happens, they can spout off any numbers they want.

Do your research, and you'll have the best chance for a cure. Good luck

BCG

Re: Excuse me for this ? But what do u call the kind of surgery on the inside of ankle to release pf?

Dr. Zuckerman on 7/31/01 at 11:00 (054957)

It is called miminial incision foot surgery on the inside of your foot, or the medial aspect of the heel. I just do it on the bottom cause no nerves or blood vessels there and much easy to get to the bottom of the heel

Re: Here's my 2 cents

Dr. Zuckerman on 7/31/01 at 11:03 (054959)

The amount of fascia cut in my opinion is determined by the physical exmination and comparison of tension in the opposite foot. Each and every patient is different so the doctor needs to understand that you don't cut 1/3 1/4 or whatever. I actually will hear the release and feel the release . This is the only way to truely determine if enough of the release was done in the first place. Just cutting and hoping that you have had enought of the release just won't work. I have done mis releases for a very long time and the sucess depends on the ability to hear and feel the release not to see the release.

Re: Re:Thank u Dr. Z

tammie on 7/31/01 at 11:15 (054961)

Hmm ok I guess that is essier for this little closed mind to comprehend lol! Thanks have a great day and hope u dont get to many stinky feet lolI always think of that , !

Re: Just need some input on surgery...

Ed Davis, DPM on 7/31/01 at hrmin (054965)

Laura:

I agree that all conservative modalities should TRULY be exhausted before surgery. A lot of people are under the belief that 'everything' has been tried but if you look closer, there was really a lot that was not done. It is not just how many things were tried but having the right things done at the right time.

A plantar fascia release generally does not lead to hammertoes. There is a procedure called a 'Steindler stripping' in which the fascia and a layer of muscles, intrinsic muscles, are stripped from the heel bone. The intrinsic muscles are small muscles within the foot which help to stabilize the foot and toe joints. Any possibility that that was what you had done?
Ed

Re: Here's my 2 cents

Ed Davis, DPM on 7/31/01 at hrmin (054969)

The decision on how much of the fascia to cut usually involves the lateral aspect of the fascia. Almost everyone agrees that the medial aspect of the fascia is to be released, the thickest part and the part with the majority of the tension. Some feel that a portion needs to be left laterally in order to help support the calcaneo-cuboid joint.

I am not particularly enthusiastic about EPF. It is a 'high tech' way to do the procedure and unfortunatley, sometimes a way to 'sell' the procedure. I am familiar with some cases in which EPF did not get 'all' the medial fibers.

Both Dr. Z and myself favor a plantar MIS approach though I occasionally do the procedures via the traditional 'open' approach.
Ed

Re: Just need some input on surgery...

laura on 7/31/01 at hrmin (054980)

Dr. Davis, I did have a plantar fasciotomy with 1/2 inch of the plantar fascia removed. I have no feeling from the incision point(instep) to my toes. I no longer have any heel pain so I guess that part actually worked. After having tests done, it was determined that my loss of feeling is being caused by the scar tissue. (that is all that shows up on an MRI) My big toe is straight and will not bend on its own, but my four other toes have become hammertoes, and will not bend at all. I still have feeling on the inside of my foot, if I step on something even as small as a pebble the pain is excrutiating. I work on my feet and after just an hour the pain gets to be unbearable but I have learned to deal with it as my doctor doesn't think that there is anything that can be done for it. Laura

Re: Just need some input on surgery...

SueD on 8/01/01 at hrmin (055052)

I had PF surgery with the inside heel small incision (3/4 release)in April of 1999. It took about nine months for my foot to be totally and completely painfree as it remains today. I would highly recommend the surgery.

Re: Here's my 2 cents

BrianG on 8/01/01 at 09:59 (055058)

Hi Dr. Davis / Dr. Z,

Even though my EPF was a failure, I feel I was at least lucky enough to heal back to where I was before the surgery. I did have some additional arch pain, but that can come with any release procedure, correct? What I'm wondering is, about the EPF. I was told that it was designed so that no nerves or arteries would be hit during the procedure. Do you think this is correct. I've run into quite a few people that the EPF did not work for, but most of us don't seem to run into the complications that other people get from the 'open' types of release.

BCG

Re: Here's my 2 cents

Ed Davis, DPM on 8/01/01 at hrmin (055115)

It can be a hard call. Seems that EPF is potentially less traumatic than the open procedure, particularly the single portal version (uses only one medial incision as opposed to the medial and lateral incisions with the original two portal method).
Ed

Re: Here's my 2 cents

john h on 8/04/01 at 12:01 (055458)

after reading many medical articles and many post from those who have had the procedure through the scope i would elect not to have this procedure done on me (patients view point). a couple of the larger Podiatrist groups in our city have dropped the procedure in favor of MIS.

Re: Here's my 2 cents

Dr. Zuckerman on 8/04/01 at 12:53 (055463)

I have been using the Mis Bottom approach since 1980. I can thank a Dr. Harvy Pilsner for this idea. I was at a convention and we were in a very boring lecture. He was sitting next to me and pulls out polariod pictures out of pocket. No one was sitting next to him, for some reason I did. I had met him years ago. He is from West Virginia. He starts to show me these pictures. and telling me about the great results. Well I start to think and then I started to actually remove the spur and cut the pf from the bottom. I had done it open before before all patients were placed into a cast. There is no question in my mind that this is the best surgical procedure for insertional pf with or without spur . It is very important to also remove some of if not all of the spur and not just cut the pf.

The EPF cuts the pf not at the level of the bone but much move distal and therefore move nerves and arteries to damage. Harvey is either in his mid 80's or not alive today. We owe him alot for this procedure.

Re: Here's my 2 cents

john h on 8/06/01 at 15:32 (055668)

dr z: what protocol do you have your patients follow after a mis PF?

Re: Here's my 2 cents

Dr. Zuckerman on 8/06/01 at 16:32 (055679)

We apply unna boot casting. We soak the foot in acetic acid soaks.
No bare feet. Gradual weight bearing . I see the patient within the first week. Some will need crutches or cane . Some can go back into stiff shoe within two. weeks. If they can't place weight on the foot . We do non-weight bearing stretching. Some patients if they have pain after one week and are limping are placed in a slipper cast. I like patients to walk but I don't want them walking thru the pain.