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PF surgery

Posted by BarryR on 9/10/01 at 19:13 (059786)

I have had PF for 3 1/2 years and have tried taping, stretching, night splints, 5 different pairs of orthotics,ESWT, NSAIDs, massage, accupucture, steroid injections, and foot/lower leg exercizes. My main problems is very tight plantar fascia and calf muscles which seem to get worse by stretching. The pain is in the middle of the medial arch, especially on the left foot. I do not have heel spurs. My main problem is standing - it seems that even with orthotics the arch falls putting pressure on the plantar fascia. I am able to walk from 5 to 30 minutes, but standing is a real killer.

My podiatrist suggests surgery (endoscopic) where the medial band of the plantar facia would be cut. He says that it won't affect the way I walk, but I don't know if I should believe him or not.

What are the risks?
What alterntives are out there? (surgery or otherwise)
Does anyone else out there have this type of PF?

Re: PF surgery

Ed Davis, DPM on 9/12/01 at 23:24 (060077)

It is incumbent upon your doc to discuss the risks of surgery with you.

The fact that your plantar fascia and achilles remains tight suggests that you may not be stretching properly. night splints can be an effective stretching modality.

Think of a ligament or tendon as made up of many tiny parallel fibers and that the fibers have great tensile strength but the fibers are not tightly adhered to each other such that the fibers can slide against each other.
If a light load or stretch is applied and maintained, the fibers eventually start to slide against each other causing the tendon or ligament to elongate. Tendons attach to muscles. Tendons have nerve end receptors within them called intrafusal fibers. Those receptors are 'sensors' which measure stretch and strain in the tendon. The sensors are connected to a nerve (afferent fiber) which carries the signal that excess stretch is occurring to the spinal cord. The spinal cord sends out a 'connecting' nerve (efferent nerve) to the muscle attached to the tendon which causes the muscle to contract. This is known as a 'spinal reflex.'

The goal is to apply a stretch or load to a tendon of sufficient intensity to cause the fibers to elongate but of insufficient intensity to activate the spinal reflex which contracts the muscle. The contracting muscle acts to protect itself from excess stretch--it is a mechanism to prevent injury.

The bottom line: one needs to apply light tension on the night splint but for a long period of time. The process cannot be rushed because as soon as the night splint is over tightened, muscular contraction occurs and that ruins things.
Ed

Re: Elongating tendons and ligaments - Dr Ed

Julie on 9/13/01 at 01:35 (060082)

Thank you for this explanation: it's very useful to me.

Re: PF surgery, not on me again !!!!

BrianG on 9/13/01 at 10:54 (060126)

Hi BarryR,

Has your doctor given you any indication of how many EPF's he has performed? His success rate? Can he prove his success rate to you?
I personally had failed EPF surgery and I am one of the lucky ones. I wasn't crippled after the procedure. I only had intense pain for about 2 months, bad pain for about 4 months. This surgury is supposed to get you on your feet quicker, with less pain. You couldn't prove it by me. But then again everyone percieves pain differently. I would get a 2nd and 3rd opinion about the different types of surgery that are available to you. Use the search feature here, it'll help alot.

Good luck on your decision.
BCG

Re: PF surgery, not on me again !!!!

Ed Davis, DPM on 9/14/01 at 11:29 (060313)

Brian:
My last response disappeared somewhere in Cyberspace. I an not particularly impressed with EPF as you may have seen by reading some of my posts and I believe Dr. Z shares my opinion on that issue.
Ed

Re: PF surgery

Gail B. on 9/14/01 at 22:19 (060408)

I can relate, sounds like we have a matched set! The standing is unbearable. I have also tried all the things you mentioned. I had the surgery on my first foot with a scalpel, and it was successful. The laser was not! GOood LUCK

Re: What is EPF??

Kathy M on 9/15/01 at 20:15 (060508)

What is EPF? I had PF release surgery 3 months ago and am wondering what all this talk is about EPF? Was that what I had done? Mine was in the outpatient surgery center - not laser surgery, regular scalpel surgery. Thanks, I am just curious.

Re: What is EPF??

BrianG on 9/16/01 at 13:14 (060585)

Hi KathyM,

There may be a little confusion here. EPF (Endoscopic Plantar Fasciotomy) is done with a knife, not a laser. In EPF surgery, the doc will use a 'kit' which allows him to make a much smaller incision, yet presumably still see enough to cut the fascia at the right location. I think what is happening, in some cases, is that the area the doctor is cutting cannot be seen all that well. Often times not enough of the fascia is cut, as in my case. I went through a lot of pain and $, for basiclly nothing. And now I may have some additional pain in my arch, as a part of the fascia was cut, just not enough of it. I'm now extremely reluctant to be cut again.

Regards
BCG

PS Lots of EPF info on the web, just use a search engine

Re: To Brian What is EPF??

Pauline on 9/16/01 at 16:42 (060605)

Brian,
This sounds similar to a laprascopic surgery without the scope for viewing.
Is this what your saying? They are cutting blind or by feel? Is any type of scope used. Do they expand the enclosed area with air or anything to have a larger space to work. I don't know if I could feel comfortable with a blind surgery if that is what EPF is.

Re: PF surgery

Ed Davis, DPM on 9/12/01 at 23:24 (060077)

It is incumbent upon your doc to discuss the risks of surgery with you.

The fact that your plantar fascia and achilles remains tight suggests that you may not be stretching properly. night splints can be an effective stretching modality.

Think of a ligament or tendon as made up of many tiny parallel fibers and that the fibers have great tensile strength but the fibers are not tightly adhered to each other such that the fibers can slide against each other.
If a light load or stretch is applied and maintained, the fibers eventually start to slide against each other causing the tendon or ligament to elongate. Tendons attach to muscles. Tendons have nerve end receptors within them called intrafusal fibers. Those receptors are 'sensors' which measure stretch and strain in the tendon. The sensors are connected to a nerve (afferent fiber) which carries the signal that excess stretch is occurring to the spinal cord. The spinal cord sends out a 'connecting' nerve (efferent nerve) to the muscle attached to the tendon which causes the muscle to contract. This is known as a 'spinal reflex.'

The goal is to apply a stretch or load to a tendon of sufficient intensity to cause the fibers to elongate but of insufficient intensity to activate the spinal reflex which contracts the muscle. The contracting muscle acts to protect itself from excess stretch--it is a mechanism to prevent injury.

The bottom line: one needs to apply light tension on the night splint but for a long period of time. The process cannot be rushed because as soon as the night splint is over tightened, muscular contraction occurs and that ruins things.
Ed

Re: Elongating tendons and ligaments - Dr Ed

Julie on 9/13/01 at 01:35 (060082)

Thank you for this explanation: it's very useful to me.

Re: PF surgery, not on me again !!!!

BrianG on 9/13/01 at 10:54 (060126)

Hi BarryR,

Has your doctor given you any indication of how many EPF's he has performed? His success rate? Can he prove his success rate to you?
I personally had failed EPF surgery and I am one of the lucky ones. I wasn't crippled after the procedure. I only had intense pain for about 2 months, bad pain for about 4 months. This surgury is supposed to get you on your feet quicker, with less pain. You couldn't prove it by me. But then again everyone percieves pain differently. I would get a 2nd and 3rd opinion about the different types of surgery that are available to you. Use the search feature here, it'll help alot.

Good luck on your decision.
BCG

Re: PF surgery, not on me again !!!!

Ed Davis, DPM on 9/14/01 at 11:29 (060313)

Brian:
My last response disappeared somewhere in Cyberspace. I an not particularly impressed with EPF as you may have seen by reading some of my posts and I believe Dr. Z shares my opinion on that issue.
Ed

Re: PF surgery

Gail B. on 9/14/01 at 22:19 (060408)

I can relate, sounds like we have a matched set! The standing is unbearable. I have also tried all the things you mentioned. I had the surgery on my first foot with a scalpel, and it was successful. The laser was not! GOood LUCK

Re: What is EPF??

Kathy M on 9/15/01 at 20:15 (060508)

What is EPF? I had PF release surgery 3 months ago and am wondering what all this talk is about EPF? Was that what I had done? Mine was in the outpatient surgery center - not laser surgery, regular scalpel surgery. Thanks, I am just curious.

Re: What is EPF??

BrianG on 9/16/01 at 13:14 (060585)

Hi KathyM,

There may be a little confusion here. EPF (Endoscopic Plantar Fasciotomy) is done with a knife, not a laser. In EPF surgery, the doc will use a 'kit' which allows him to make a much smaller incision, yet presumably still see enough to cut the fascia at the right location. I think what is happening, in some cases, is that the area the doctor is cutting cannot be seen all that well. Often times not enough of the fascia is cut, as in my case. I went through a lot of pain and $, for basiclly nothing. And now I may have some additional pain in my arch, as a part of the fascia was cut, just not enough of it. I'm now extremely reluctant to be cut again.

Regards
BCG

PS Lots of EPF info on the web, just use a search engine

Re: To Brian What is EPF??

Pauline on 9/16/01 at 16:42 (060605)

Brian,
This sounds similar to a laprascopic surgery without the scope for viewing.
Is this what your saying? They are cutting blind or by feel? Is any type of scope used. Do they expand the enclosed area with air or anything to have a larger space to work. I don't know if I could feel comfortable with a blind surgery if that is what EPF is.