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5 WKS POST OP

Posted by Tonya on 6/11/02 at 10:21 (087083)

In two days i will be five weeks post op from an open plantar fascia release. I posted at three weeks and wanted to update on my progress. I am still very pleased with the surgery. I am now able to wear my regular shoes(with orthotic support), and I can toddle around in the house rather well without my crutches. If I have to walk much further than that I do still rely on the crutches for the support, because it does not take long for my foot to become sore, and start to swell. The foot is still tender, but each day it gets better. I am only icing now when i need to. Call me crazy, but I actually enjoyed doing the laundry yesterday. I still spend a lot off time off the foot, but it sure is nice to begin to be mobile again. The only discouraging thing for me has been that my left foot has started to flare up badly, but my doctor warned me ahead of time that this could happen, so I was somewhat expecting it. I can say though that it is nice to have at least one foot that is not stiff when I get out of bed in the morning. I don't run into as many walls. As for my kids, they are still being really good about all of this. They go next week to grandma and grandpa's for the summer, and are very excited. My husband has also been a real trooper. Although, i look forward to the day i can tolerate standing to cook. We have eaten some rather 'interesting' meals over the past few weeks. At this point in time the only advice i can give post op patients is to have some sort of supportive shoe on your foot at all times. Standing in the shower kills my foot because of being barefoot. I want to thank everyone who so graciously responded and gave advice to me after my three week post. It has been so nice to be able to follow along with what others are going through and maybe offer support to someone who may need it. I've had several of my questions answered that otherwise I would have called the doctor about. Example being the outside of my foot acheing. Several people responded that this was normal in this stage of healing. You guys have been my saving grace. Thank you and God Bless.

Re: 5 WKS POST OP

john h on 6/11/02 at 11:17 (087106)

Good to hear about your positive progress Tonya. Facts are that surgery cures many more people than are made worse. Most of our people on the board are ones who have been made worse. We rarely hear the success stories.

Re: 5 WKS POST OP

Laurie R on 6/11/02 at 11:21 (087108)

Dear Tonya , How wonderful to hear you are doing so very well... I'm also 5 weeks post opp. I had a PF Open release and a TT release and my tendons cleaned out and a groth removed ... I am doing really well also . I am so glad I had the surgery as well....

I like you have a wonderful family , my hubby has been so very great to me . Also my kids have done a great job .. You sound just like me , I also did some laundry the other day and I was so happy to be able to do it . After all these weeks of doing nothing , it feels so good to do a few things ...

Take care and keep us poted and again I am so glad to hear you are doing so well.....

Laurie R

Re: 5 WKS POST OP

Dee on 6/11/02 at 13:28 (087131)

You go girl!! So glad to hear that you are doing excellent!!! It's funny how something as mundane as laundry can actually be exciting isn't it?? I am 1 week and 1 day post op and go to the doc today to have my stitches removed. I too am doing excellent!! Still just putting some weight mostly on my toes, but I can already tell that I am not going to have the severe pain in my heel like I had before my surgery. I can move my foot more now than before and don't have hardly any pain at all when I do. I am still forcing myself to stay as completely off the foot as possible because I tend to be impatient and wanting to walk NOW!!!!! I fully expect my doctor to release me to go back to work next week. Even though I have enjoyed not having to be at work, I am starting to miss it and am actually looking forward to returning. (Did I really say that???) :-)

I just want to thank you and everybody else on these boards for being so encouraging and supporting. I think it's important to let people know that we have been where they may be now and that it can and usually does get better. I know personally that I have learned so much from 'chatting' with you guys on here and that knowledge has eased my fears greatly. I hope you and everybody else continues to improve. Have a pain free wonderful day!!!

Re: 5 WKS POST OP

Tonya on 6/11/02 at 13:46 (087139)

Dee, I'm glad to hear you are doing so well. I have been thinking about you. Just take it slow, slow, slow. Believe me, your foot will let you know what you can and can not do. Even though I can walk on mine, i still am not comfortable driving. The constant pressure is just too much. I hope all goes well with you at the doctor. Although, it was almost three weeks before i had my stitches removed, my doctor cleaned my wound at one week with iodine swabs before casting me. I can tell you that the surgery site was still very sore. As we have all witnessed on this board, we all heal very differently. Seems you and I are some of the lucky few that have had little to no complication. Keep us updated on your continued great progress. Tonya

Re: 5 WKS POST OP

Tonya on 6/11/02 at 13:50 (087140)

Laurie, Listen to us!!!!!:) Two months ago we would have given anything for someone to do our laundry. Isn't it funny the things you enjoy when you've done nothing but sit for over a month. I wish you luck with your healing in the weeks/months ahead.

Re: cure rates

Ed Davis, DPM on 6/11/02 at 19:41 (087190)

John:
You are correct in that surgery works more often than not. The perplexing aspect is the inability to explain why surgery fails in a number of cases and as such, the inability to offer good predictablity of outcomes.
Ed

Re: 5 WKS POST OP

kay f on 6/11/02 at 20:02 (087193)

i'm so happy to hear you are doing so well. my surgery is next tuesday and i am looking forward to having some relief in my pain. i'm thinking positive here. i went to see my family doctor today and he prescribed me some antidepressants so i think once i get them going in my system i will feel better mentally. i've never had to deal with depression before. i was so embarrassed i nearly started crying while talking to the doctor.
but anyway i want you to keep us updated. i will be right behind you in your progress i hope.
thanks for posting
kay

Re: 5 WKS POST OP

kay f on 6/11/02 at 20:04 (087196)

laurie thanks for your post also. it really helps people who have to have surgery and are scared it won't work. i've been through everything with this p.f. and i am ready for some good news.
kay

Re: cure rates

Joe S on 6/11/02 at 20:16 (087200)

I believe much of the failure of the surgery is due to an improper diagnosis. Also, when performing an open plantar fasciotomy, you still can't actually see the plantar fascia (unless you do an instep plantar fasciotomy). With this being said, some surgeons just cut away at something in the medial aspect of the heel thinking that they got the plantar fascia. I see it periodically. I've done it as well. The one thing I listen for after I clamp the plantar fascia, is a crunching sound when I cut the plantar fascia with a heavy scissor. Typically sounds like celery crunching. This is done under tension in order to assess the medial band of the plantar fascia being cut. I saw a lady today who had a post op incisional neuroma overlying after a plantar fasciotomy. Thankfully, it was not done by me. Anyway, most people are much better after surgery than are worse.

Re: cure rates

DR Zuckerman on 6/11/02 at 20:35 (087202)

One of the major reasons for failure of plantar fascia surgery is due to cutting a structure that was never suppose to be cut in the first place. Another reason is that you should only do pf releases for heel spur syndrome and no other reason in a heel pain patient. If you cut the plantar fascia in a patient that has no first step morning pain you are could have additional pain and foot problems. As podiatrist we talk about biomechanics and how important bimechanics are then we go ahead and cut a very important biomechanical structures .Makes no sense to me.

There is so much degenerative joint disease in the foot from pf releases down the road. Most physicians either don't recognize this or treat this as a new problem. Yes there are alot of pain free results but the idea to cut the fascia makes no sense to me.

Re: Kay

Tonya on 6/11/02 at 20:42 (087203)

Kay, Thinking positive is exactly what you should be doing. Don't be embarrassed about the antidepressants. If that is what you need in order to make it through the day, then so be it. I've said it before, constant daily pain can wear you down. It could make the most positive of people depressed. I hope that all goes well with you. If you ever need anyone to talk to outside of the board, please email me. The address is (email removed). You always have shoulders here on the board too. We've all been through it. I will be out of town the 18th to 23rd of June, but will occassionaly check my mail. Regardless, keep us updated. God Bless. Tonya

Re: cure rates

Tonya on 6/11/02 at 21:03 (087207)

Dr Zuckerman, It seems from this response and a few other responses that I have read of yours that you are not very keen on the fascia release.I had the instep fascia release. I did not know there was a difference between and open and instep fascia release. I just looked at my discharge papers and it says instep fascia release. If you are presented plantar fasciitis symptoms from a patient, how do you treat them? I do believe that you recommend ESWT, but what if we either cannot afford it, or our insurance will not cover it. I am talking about a patient who has exhausted all conservative therapies. Please do not think that I am challenging your knowledge, because I am genuinely asking. My husband is in the military and since I am not the soldier, there is only so much they will approve regarding my treatment. I am very pleased with my surgery on my right foot, but am looking at surgery on my left too. If surgery could be eliminated on my left, I would be thrilled. If there is another treatment out there somewhere that I could ask my doctor about, I would. I just do not know of any. In case you have not read my past posts. I have already been through tapings, strappings, iceing, stretching, cortizon injections(twice in each foot), orthotics, night splints, and physical therapy. Although, i do not remember the exact name of the modality that I had done, I can describe them. The took little pads with electrodes on them. On one pad they saturated it with a medicine and applied it to the tendon area, and applied one to my inner calf. This was done to both feet at the same time. They hooked what looked like little jumper cables up to each of the pads. They said that electric current would push the medicine into the tissue. I had ten of these treatments on each foot. My last treatment was the friday before my surgery. It took a bit of the pain away immediatly after the treatments, but I did not experience any real relief. Any input you can give me would be appreciated.

Re: cure rates

DR Zuckerman on 6/11/02 at 21:38 (087212)

Hi

If all fails and ESWT isn't a logical treatment for you I would then do Miminal incision plantar releases. I do this procedure thru the bottom. It has proved tobe very effective in my hands however complications do come up and in very rare cases pain that is permenent.

Re: cure rates

Joe S on 6/11/02 at 23:08 (087219)

In a perfect world, no structure should ever be cut. We don't live in a perfect world however. I don't recommend plantar fascial releases hardly at all. Only as a last resort. I also don't recommend ESWT as a primary procedure. If all conservative measures fail then these two alternatives exsit. Those with the resources undergo ESWT and those without whose insurance will not cover it have three options. Take out a loan for ESWT, have surgery (by wharever means), or live with the pain.

Re: cure rates

Tonya on 6/11/02 at 23:16 (087220)

Thanks for the advice. Actually, what you recommended is what I believe I had done. I had said on my discharge papers the nurse had written that I had an instep release, but I think she was mistaken(now that's comforting). That would be towards the side of my foot, right? What I have is a small incision(that took 5 stitches)in the shape of a cresent moon. Again, thanks for the info.

Re: cure rates

Tonya on 6/11/02 at 23:19 (087221)

Unfortunately, I don't believe I have what it takes to live with the pain. Nor the means to take on a loan, so I guess I have to take what is being offered, and pray all goes well.

Re: cure rates

Joe S on 6/11/02 at 23:19 (087222)

You had iontophoresis. Basically, the difference between an instep plantar fasciotomy is that the incision is made more in the arch. You can actually see how much of the plantar fascia you are cutting. The incision is somewhat larger than the traditional open or semiclosed incision. The success rates are about the same. There is one source that you can go to and do a literature search on the various heel spur surgery techniques. http://www.abps.org (the American Board of Podiatric Surgery), http://www.apma.org . You can do a literature search under their journal articles for basically any type of surgical procedure.

Re: re: TONYA, LAURIE, AND DEE

Missy B on 6/11/02 at 23:24 (087223)

How wonderful to hear encouraging news from all of you. It sounds as if each of you is experiencing some positive results of your surgery. Just remember that REST is still important in the weeks and months ahead, so try not to overdo it as you begin to feel better.
Today, I am 5 months post PF/TT release and am holding at what I consider to be an 80% improvement over my pre-surgery pain. I say 80% because although the pain and numbness associated with the TT entrapment has completely disappeared, I still have some residual PF soreness. However, I got my new custom orthotics yesterday, so my pod and I are hoping that these, along with continued stretching exercises and some icing, will relieve most, if not all, of the PF soreness in the months to come.
At least now I can get thru my day at the hospital with a smile on my face instead of tears in my eyes.
I hope you all continue to improve in the days and weeks ahead - please keep us posted. I will be thinking of you and wishing you the best.
Missy B.

Re: cure rates

Joe S on 6/11/02 at 23:26 (087224)

Tonya, I just posted a couple of websites that you maybe able to find some more info on long term cure rates for different plantar fascial releases. Someone is stating on this board that 100% of all subject who underwent ESWT by a certain machine had 92% relief. This is not accurate. In a true, double blinded, scientific study, there are going to be positive outcomes and negative outcomes in both groups. If the study includes only one treatment protocol and the examiner is reporting a certain success rate then there is no validity to the study. Some people who get the placebo will respond positively to treatment when in effect no treatment was ever rendered. I take it that you're other foot is doing ok after the instep fasciotomy. If so, then why not opt that again on the one that is now hurting? ESWT is not the end all cure all to heel pain. What if you spent a few grand and were no better? Then you'd be out of money and still would have a painful foot.

Re: cure rates

Joe S on 6/11/02 at 23:28 (087225)

The MIS procedure is directly on the bottom of your foot. An area prone to painful thick, hypertrophic scarring.

Re: cure rates

Tonya on 6/12/02 at 00:54 (087232)

Joe, I plan on having the same procedure on the left(and yes, my right foot is doing wonderfully). I have just caught on that there are a few doctors and patients that post on here that are totally against a fascia release. I was just curious as to what they would recommend if they are so against it. To be truthful, until reading posts on this board, i had never heard of ESWT. Again, my husband is in the Army and there is only so much that Tricare(military med. coverage) will pay for. I am very comfortable with my doctors ability to give me the best care that he is allowed by the Army, and since he never mentioned ESWT, I assume that it is not an option for me. Lord knows he had me doing everything else. He was very strict about even contemplating surgery until all conservative therapy was exhausted with me. I was asking DR.Zuckerman if ESWT is not an option and conventional therapy is exhausted, what he would recommend to a patient such as myself if he was totally against a fascia release. I am always open to any advice I can get. Whether be it by another doc or another patient. Having you guys respond to me has a) allowed me to be confident about my surgery decision and b)shown me that my doctor has given me the best care he can. Let me tell you, at least on the Army base we are on, a doctor that will take the time to speak to you past 15 min. is rare. Maybe it's because he is a specialty doctor, i don't know. You hit the nail by pointing out that not all of these posts are accurate. Which just proves that all of us as patients or potential patients must research everything we are being told. Again, I thank everyone who posts on here,whether you be a doctor or a patient. I'll be sure to look up the websites you noted. As for spending a couple of grand....unfortunately, on an E-4 pay with three kids, I don't even have 1/2 a grand to spend. So, I have to take what is recommended by my doctor, and hope for the best. Thanks for the info.

Re: The cure rare is a direct quote from the dornier study

DR Zuckerman on 6/12/02 at 01:24 (087233)

Dear Joe S DPM

It was Dr.Z who stated that the in a one year follow up with the dornier epos ultra those who underwent treatment has a 92% reduction in pain. This is a direct quote from the one year follow of the FDA study In addition the average VAS score was 0.6 . The pre- treatment VAS score was 7.7. I only quote from the study.

The standard for recommendation for ESWT is the pain should have pain for at least six months and failed conservative treatment. It isn't ever used as a primary procedure.

The above study EXCLUDED the placebo group and only included the treated patients.

Patient do have options and so long as they realize that with plantar fascia releases you stand the option of a foot worse off then before which hs nothing to do with a Wrong diagnoses then go for it

Over the past twenty two years I have seen just too many pf releases in patients that are will never walk again.

Re: cure rates

DR Zuckerman on 6/12/02 at 01:33 (087235)

just curious have you ever seen an mis procedure with the incision on the bottom of the foot?. Have you even seen a medial incision from a open release with a painful hypertropic scar ?

I have seen quite a few open release done from the side with nerve pain, hypertrophic incision and in some cases keloid.

I am only talking about incisions.

Re: cure rates

john h on 6/12/02 at 10:18 (087286)

Dr. Ed: Dr. Gordon in Canada said to me that there is a percentage of people that just are not going to be cured no matter what you do. That is not good to hear but probably is on the mark. However, we all should approach this with the thought we are not one of those. I think all pilots in combat develop a mentality that they will never be the one to be shot down inspite of the fact that statistically they may have a 30% chance of being shot down. We lost over 6000 helicopters in Vietnam. Sure glad I did not know those numbers when I was flying them. I was one of the 6000.

Re: cure rates

john h on 6/12/02 at 10:24 (087291)

Tonya: You mention discharge papers and your eamail begins with 'paratrooper'. Were you a paratrooper? A couple of years ago I corresponded with a paratrooper at Ft Bragg who had terrible foot problems. He had surgery on his achilles and a cheilectory. Last word I had from him he was back to jumping and doing great.

Re: cure rates

Tonya on 6/12/02 at 10:32 (087295)

John, I was meaning my hospital discharge papers from when I had the surgery done. My husband is the paratrooper, because I see no need to jump out of a perfectly good airplane. I am just an ordinary Army housewife. We live on Fort Bragg, and I think that I live in 'Bad Foot Country'.

Re: Dr. Zuckerman/Dr Ed

john h on 6/12/02 at 10:32 (087296)

Dr. Zuckerman/Dr Ed: As you know I had the Baxter Procedure performed on my left foot. The more I think about this the more I think it is not really a PF release. A 1/2' semicircle wedge of fascia is removed from over the Baxter Nerve at a point near where the fascia attaches to the heel on the inside of the foot. Basically if you are only cutting 1/2' of fascia I assume that is no more than 15% of the width of the fascia so you have a very minimal release which is why your foot integrity remains very much the same. Obviously even a 10-15% release releaves some stress on the fascia but I guess the primary thinking with this procedure is to reduce any pressure on the Baxter Nerve and any release is just secondary outcome? Am I right or wrong in this thinking?

Re: cure rates

john h on 6/12/02 at 10:38 (087299)

Joe: In my readings I find that 90% of all the reported PF cases each year (3 mil - 6 mil)are cured with the standard conservative meaures so it seems clear that what ever you guys are doing works for the vast majority of the people. The folks on this board are part of the other 10% and I would guess most of us have tried every conservative measure and then some.

Re: cure rates

john h on 6/12/02 at 10:45 (087301)

Most of the nmbers I see Joe are for a success rate of 70-80%. Success being defined by many as a 50% reduction in pain. Lots of numbers out there from different sources. Some of the German stats are based on a very large base. Bayshore has been in the business a long time and I tend to think their stats are worth considering when making a decision. When you are in as much pain as many on this board you tend forget about statistics and the scientific method and will try most anything. This includes me.

Re: cure rates

john h on 6/12/02 at 10:47 (087302)

Joe: Is MIS always from the bottom of the foot? I thought i have seen 1-2 stitch procedures that were on the edge and curved to the bottom.

Re: Dr. Zuckerman/Dr Ed

scott r on 6/12/02 at 10:47 (087303)

John, the fascia is about 3/4' wide where it attaches to the heel. The baxter proc is meant to releave nerve problems but also relases some of the fascia

Re: cure rates

john h on 6/12/02 at 11:01 (087305)

I had much rather spend $3000 or more dollars on ESWT knowing there was virtually little risk of being made much worse.If that did not work then surgery would be my next alternative. My first question and commments to my surgeon were (1) what are the chances this will make me worse (2) what are the chances this will make be better? I told him I could live with the possibility it would not work but did not want to end up like some of our people with failed surgeries. Even with ESWT if it works great if it fails and I am no worse I have lost some money but still have hope and not possible made worse for life, Once that fascia is cut there is no turning back.

I am not against surgery. I had it! I did choose the Baxter Procedure because it seemed like the procedure with the least likely chance of being made worse. Possible a MIS might have given me a better chance for a cure but I was more concerned with being made worse. Many doctors will not perfom PF surgery under any circumstances.

As I know, a lot more people have successful surgeries than failed ones so surgery will be with us for the forseeable future as it should be.

Re: Something else to consider

BrianG on 6/12/02 at 20:47 (087368)

Hi Tonya,

There is one more possible treatment to consider. If you don't feel comfertable with surgery at this point, you may be able to put everything off for a few years by seeing a pain management specialist. They will prescribe enough pain meds so that you can buy some more time. No telling what new, or refined treatments may be available in the next few years. Check out this web site if you are interested, it's a start: http://www.pain.com

Good luck
BrianG

Re: cure rates

Joe S on 6/12/02 at 21:40 (087381)

Actually, I saw your video that you posted. It looked like a plantar approach to me. And, it still appears to be a blind procedure. I have seen a painful hypertrophic scar from a medial incision as well. I booked an excision of a this hypertrophic scar just yesterday. I have also seen patient's who have had these MIS 'surgeons' 'decompress' the calcaneus with drill holes and go on to a calcaneal fracture and develop horrible STJ arthritis that requires a triple arthrodesis. Yes I have seen it. I have seen post op cases where a surgeon does both a plantar fasciotomy as well as a tarsal tunnel release in which both have gone onto failure and the development of RSD. No one wants this complication irregardless of the procedure of choice.

Re: cure rates

Joe S on 6/12/02 at 21:48 (087386)

No MIS is not always from the bottom of the foot. As far as heel spur surgery goes, there are a couple of medial approaches. You can take a nonweighbearing xray (lateral view), measure the distance from the posterior aspect of the heel and the inferior most aspect of the heel. These two lines can be intersected at the medial calcaneal tubercle (insertion of the plantar fascia) or where the actual spur is. From this measurement, you can dictate where your incision is. 9/10 times this puts you right on the money. All you need to do is a small 2cm incision. This is somewhat bigger than the incision for the EPF and quite a bit smaller than the incision for the Instep Plantar Fasciotomy. There are many good MIS procedures out there. An EPF could be considered a MIS procedure just by the size of the incision alone. I did an ankle arthroscopy today which technically you could consider a MIS procedure until I opened up her lateral ankle and repaired her anterior talofibular ligament.

Re: Dr. Zuckerman/Dr Ed

Joe S on 6/12/02 at 21:54 (087388)

There is an article by Alan Banks, a podiatrist from Atlanta Georgia who is also the residency director of probably the most well known and most well respected podiatric surgical residency in the U.S. I posted this article some time ago and it discusses this procedure in detail. The incisional approach for this procedure is different from a 'typical' heel spur incision. http://www.apma.org is were the article is at. Actually, here it is:

--------------------------------------------------------------------------------
Analysis of Release of the First Branch of the
Lateral Plantar Nerve

JAPMA VOLUME 90 / NUMBER 6 / JUNE 2000

Robert M. Goecker, DPM*
Alan S. Banks, DPM†

*Submitted during third-year residency, Northlake Regional Medical Center, Tucker, GA. Mailing address:1961 Floyd St, Ste C, Sarasota, FL 34239.

† Member, The Podiatry Institute, Tucker, GA; Director of Residency Training, Northlake Regional Medical Center, Tucker, GA.

--------------------------------------------------------------------------------

The authors conducted a retrospective study of the release of the first branch of the lateral plantar nerve in the treatment of chronic heel pain unrelieved by conservative treatment modalities. A total of 17 patients (18 feet) were evaluated following external neurolysis for heel pain caused by entrapment of the first branch of the lateral plantar nerve. The average postoperative follow-up time was 32.8 months, with a range of 10 to 72 months. Every patient deemed the surgery successful. At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. There was one postoperative complication, medial calcaneal nerve entrapment; it was successfully treated with neurectomy. (J Am Podiatr Med Assoc 90(6): 281-286, 2000)

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Plantar heel pain is usually attributed to plantar fasciitis or heel spur syndrome. In certain individuals, however, a different entity can produce similar pain and symptoms. Several authors have described a neurogenic source of heel pain: entrapment of the first branch of the lateral plantar nerve.1-12

The first branch of the lateral plantar nerve is a mixed nerve with both motor and sensory fibers. Muscles supplied by this nerve include the abductor digiti minimi, flexor digitorum brevis, and quadratus plantae. Sensory fibers supply the calcaneal periosteum, the long plantar ligament, and the skin at the plantar lateral aspect of the foot. This branch originates from the lateral plantar nerve proximal to the abductor hallucis and then dives through the fascia at the superior margin of the abductor. The nerve courses distally between the abductor hallucis muscle and the medial edge of the quadratus plantae until it reaches the inferior margin of the abductor fascia. There it turns laterally between the flexor digitorum brevis and the quadratus plantae.1 The nerve at this point lies adjacent to the calcaneus approximately 0.5 cm distal to the medial tubercle of the calcaneus.2, 3 Failure of traditional heel spur surgery may be due to damage and subsequent entrapment of the first branch of the lateral plantar nerve or an inadequate release of a primary neurogenic source of heel pain. Obviously, the nerve is not released through the traditional open heel spur surgical approach. This nerve branch should not be confused with the medial calcaneal nerve, a purely sensory nerve that lies in the superficial fascia of the heel.4, 5

In 1963, Tanz6 proposed the first branch of the lateral plantar nerve as an overlooked source of plantar heel pain, and he demonstrated the nerve's anatomy from cadaveric dissection. However, it was not until 1981 that Przylucki and Jones3 correlated actual patient symptoms with this structure. Their surgical treatment for this condition consisted of excision of the nerve. Subsequently, other authors reported successful treatment of this type of chronic heel pain with external neurolysis rather than nerve excision.1, 4, 5, 7, 8, 10-12

Baxter and Thigpen7 in 1984 described two possible sites of entrapment. The first is the sharp fascial edge of the abductor hallucis muscle where the nerve changes course and turns laterally. Another possible site is the medial ridge of the calcaneus where the nerve passes beneath the tuberosity and origin of the flexor digitorum brevis and the plantar fascia. Therefore, nerve impingement may be caused by an increase in mass, such as a calcaneal spur, within the flexor digitorum brevis. Rondhuis and Huson13 concluded that the exact site of the entrapment is where the nerve passes between the taut deep fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle (Fig. 1). Pronation, muscle hypertrophy, or other sources of irritation have been cited as instigating events that may irritate the nerve as it passes through the fascial port of the abductor hallucis.

Patients with heel pain secondary to nerve entrapment may present with slightly different symptoms than individuals suffering from plantar fasciitis. In the former condition, the pain is usually not as great in the morning or after periods of rest, but seems to be more pronounced after activity. Przylucki and Jones3 noted that compression of the first branch of the lateral plantar nerve may occur by physiologic motion secondary to pronatory forces. As the foot is pronating, the tension of the fascial structures increases, resulting in compression of the nerve. This suggests that the nerve compression may be not only static (constant) but also dynamic and can worsen with pathologic gait patterns.

However, in some patients a history more similar to that associated with plantar fasciitis may be described. Chronic inflammation of the plantar fascia may coexist with, and possibly predispose to, entrapment of the first branch of the lateral plantar nerve.4, 5 Therefore, the patient may initially have some component of plantar medial heel pain as well. In such cases, the plantar fascial symptoms will tend to respond to the conservative modalities, but the symptoms related to the nerve entrapment may tend to persist. In some instances, the patient may complain of pain radiating toward the lateral aspect of the heel following the normal anatomical course of the nerve. There may be associated motor weakness of the abductor digiti minimi indicated by the patient's inability to abduct the fifth toe (Fig. 2). Abduction of the fifth toe may be a difficult task for many people to perform, but in some individuals with this entrapment, a difference may be observed between the symptomatic and asymptomatic sides.

Regardless of the history, the diagnosis of entrapment of the first branch of the lateral plantar nerve may be made during the clinical examination. The exact source of the patient's symptoms may be determined by careful palpation of the plantar aspect of the heel. Clinically, the pathognomonic sign of this entity is greater pain with compression over the medial aspect of the heel than plantarly (Fig. 3). Hendrix et al8 labeled this test the nerve compression test. Palpation in this region pinches the nerve between the deep fascia of the abductor hallucis and medial caudal margin of the quadratus plantae, resulting in pain and possible paresthesia.1 Hendrix et al8 have also found that plantarflexion and inversion of the foot (Phalen's maneuver) may be helpful in diagnosing entrapment of the terminal branches of the tarsal tunnel, including the first branch of the lateral plantar nerve. This movement reduces the width of the porta pedis and causes the superior margin of the abductor hallucis to compress the nerve, producing nerve impingement signs and symptoms. The nerve is also felt to be compressed at the exit site of the fascia between the abductor and flexor brevis.4, 5

The role of other diagnostic tests, such as electromyography and nerve conduction velocities, has been described by Schon et al.9 They found electrophysiologic abnormalities in 23 of 38 symptomatic heels, although careful review reveals that abnormalities in the lateral plantar nerve were found in only 7 patients (16%). It is also worth noting that the first branch of the lateral plantar nerve is technically difficult to isolate. It must therefore be emphasized that diagnostic tests are not a substitute for good clinical evaluation. If one does not trust a clinical diagnosis of nerve entrapment, technetium bone scans and magnetic resonance imaging (MRI) evaluations can be used to rule out an inflammatory source of heel pain. In the first few cases evaluated by the authors, patients underwent technetium bone scans and MRI evaluations, both of which failed to demonstrate inflammatory change in the heel area. This suggests that in these patients the pain is more consistent with nerve entrapment. Therefore, simple release of the plantar fascia will have limited effects on the symptoms.

The purpose of this article is to report on the success and long-term efficacy of release of the first branch of the lateral plantar nerve in those patients who failed to respond to conservative treatment modalities.

Materials and Methods

A total of 17 patients (18 feet) with painful medial heel pain were first treated with conservative modalities, such as padding, strapping, orthoses, various forms of immobilization, cortisone injections, and diagnostic nerve blocks. All patients had received extensive conservative treatment. Some of the patients had received conservative care by other physicians prior to surgical intervention by the authors. Anyone with prior heel surgery was excluded from the study. In each of these cases, the diagnosis of nerve entrapment was based on a positive clinical history and physical diagnostic findings consistent with entrapment of the first branch of the lateral plantar nerve. No other diagnostic modalities are necessary or routinely used by the authors for this condition. Surgery was elected in recalcitrant cases. The surgeries included in the study were performed over a 5-year period. All patients' charts were reviewed, and each patient was evaluated by means of a follow-up examination or a telephone interview. The outcome of the procedures was assessed by means of a questionnaire (Fig. 4).

The surgical technique that was used consists of an oblique incision made over the medial aspect of the heel overlying the course of the first branch of the lateral plantar nerve. The distal extent of the incision ends just beyond the junction of the calcaneal tuber and the plantar fascia. When the incision is oriented in this manner, it remains relatively parallel to the branches of the medial calcaneal nerve; this creates less potential for postoperative entrapment of these structures (Fig. 5).

Dissection is carried through the subcutaneous tissue until the deep fascia over the abductor hallucis can be identified. The superficial fascia is then bluntly separated anteriorly and posteriorly so that the abductor fascia may be clearly visualized. A carefully controlled inverted T-incision is then made, with the horizontal component of the T beginning at the inferior margin of the deep fascia overlying the abductor hallucis muscle. The vertical incision is then made extending proximally from the middle of the horizontal arm to the superior aspect of the abductor hallucis muscle belly. The muscle belly of the abductor is freed from the fascia at the superior margin and retracted inferiorly, exposing the fascia separating the abductor hallucis from the quadratus plantae. A vertical incision is then made through this deeper fascial layer, and a segment of tissue is removed. This should eliminate any constriction of the first branch of the lateral plantar nerve. As the nerve may also be compressed at the inferior edge of the abductor muscle, this fascia deep to the abductor hallucis muscle belly is vertically sectioned as far inferiorly as possible. The abductor muscle is retracted superiorly, and any remaining intermuscular fascia between the abductor and flexor digitorum brevis is sectioned. This circumferentially releases the fascia around the abductor hallucis muscle belly.

Next, a small portion (approximately one-quarter) of the medial aspect of the plantar fascia is sectioned to completely free the abductor hallucis and eliminate any potential irritation at this level. However, the windlass effect of the plantar fascia is maintained. Sometimes, if it is deemed necessary, an inferior calcaneal spur is gently removed with hand instruments. A Freer elevator is usually placed over the spur to prevent damage to the soft tissues and nerve at this level.

Following surgery, the patient is kept nonweightbearing for 3 weeks. A cast or posterior splint, as opposed to a soft bandage alone, has worked well. It is felt that maintaining the foot in a neutral position prevents coaptation of the incised fascial tissues.

Orthotic support is reinstituted following surgery, especially in patients in whom the plantar fascia is partially sectioned. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and the lateral column. Pain or discomfort in this region was noted postoperatively, despite significant improvement in the heel. This generalized cramping, achiness, and midfoot pain tends to resolve over time and is effectively treated with biomechanical support.

Results

Seventeen patients (18 feet) who had undergone release of the first branch of the lateral plantar nerve using the previously described technique were available for follow-up clinical or telephone evaluation. The average duration of heel pain prior to surgery was 21.2 months, with a range of 6 to 120 months. The time elapsed since surgery ranged from 10 to 72 months, with an average postoperative follow-up time of 32.8 months. Every patient deemed the surgery successful. On a pain scale of 0 to 4, all patients were asked to rate their pain both preoperatively and postoperatively (Table 1). At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. The average preoperative heel pain rating was 3.67, and the average postoperative pain rating was 0.5. A paired t-test was performed on the pain level data, revealing a statistically significant difference to a level of P< .001. There was one postoperative complication, medial calcaneal nerve entrapment, which was successfully treated with neurectomy. This patient is currently asymptomatic.

Three patients complained of a dull pain and a feeling of weakness across the top of the foot between 5 and 10 months postoperatively. Symptoms in this area can probably be attributed to the 'settling phenomenon' that occurs after partial plantar fasciotomy. Thordarson et al14 showed a progressive loss of the arch-supporting function of the plantar fascia as the fascia was sequentially sectioned from medial to lateral. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and subsequent pain.

Two patients also experienced vague lateral column pain. Both of these events were transient. In order to protect the midfoot and lateral column from increased stress after plantar fasciotomy, the authors section only the most medial expansion of the plantar fascia and suggest the use of postoperative orthoses.

Discussion

The vast majority of patients suffering from heel pain achieve symptomatic relief with conservative measures. However, it is important to remain aware of sources of heel pain other than plantar fasciitis. Although reports of neurogenic heel pain have been linked to medial calcaneal nerve entrapment, tarsal tunnel syndrome, and heel neuromas, recent literature suggests that entrapment of the mixed (motor and sensory) nerve to the abductor digiti minimi may be a common source of medial heel pain.1-12 Histologic examination of the nerve branches that have been excised under the described intermuscular septum between the abductor hallucis and quadratus plantae revealed evidence of hypertrophy, perineural fibrosis, increased endoneural collagen, and loss of myelinated fibers consistent with nerve entrapment.1, 3, 7

Once a diagnosis of nerve entrapment is made, conservative treatment modalities similar to those used for plantar fasciitis are instituted. However, it is the authors' experience that these patients demonstrate a less positive response to conservative and supportive treatment modalities. In these cases, a surgical approach that deals with potential nerve entrapment is employed.

As with any procedure, surgical approaches vary and have been adapted over time. Przylucki and Jones3 first described surgical management of this condition. Their approach involved removal of the calcaneal exostosis, plantar fasciotomy, and excision of the muscular branch of the lateral plantar nerve to the abductor digiti minimi. The procedure was performed in only three cases, and the incision placement and exact technique were not discussed.

Baxter and Thigpen7 performed the first large retrospective study of neurolysis of the first branch of the lateral plantar nerve. They performed the procedure on 34 heels using a modified DuVries heel spur incision. They recommended releasing the deep fascia of the abductor hallucis muscle and, if necessary, sectioning a small portion of plantar fascia as well as excising a small portion of a plantar heel spur, decompressing the nerve. They also noted that complete plantar fascial releases and heel spur resection should be avoided.

Henricson and Westlin10 performed the neurolysis through an oblique curved incision extending from below the medial malleolus toward the medial anterior edge of the heel pad. Kenzora11 used a plantar midline incision. These two techniques were used to avoid complications of medial calcaneal nerve injury secondary to the DuVries incision.

Baxter and Pfeffer1 published the results of a retrospective study involving 69 feet that underwent neurolysis. The incisional approach was modified to an oblique vertical incision over the medial heel similar to that described by Henricson and Westlin.10 This incision parallels the course of the nerve and is less likely to injure the medial calcaneal nerve. However, Baxter and Pfeffer still reported two medial calcaneal nerve entrapments with their new incision. The authors, as well as Sammarco and Helfrey,12 have also used the oblique vertical medial heel incision successfully. Even with this incision, extreme caution must be employed at the superior aspect of the incision to avoid injury to the medial calcaneal nerve branch. In the authors' review of 18 surgical procedures, one patient did experience a medial calcaneal nerve entrapment, which was successfully treated with nerve excision.

Recently, Hendrix et al8 proposed a transverse medial oblique approach that allowed them to decompress not only the first branch of the lateral plantar nerve but also the posterior tibial, medial plantar, and lateral plantar nerves. They released the terminal branches of the posterior tibial nerve because of their belief that the chronic heel pain is related to distal tarsal tunnel syndrome. The authors of the present article believe that it is not necessary to decompress the other distal branches of the posterior tibial nerve (tarsal tunnel release) concomitantly with the first branch of the lateral plantar nerve, especially when a limited incision is used for exposure and release.

Finally, one must consider the possibility of plantar fasciitis or heel spur syndrome coexisting with the nerve entrapment. Chronic inflammation from plantar fasciitis and large calcaneal spurs have been linked etiologically to entrapment of the first branch of the lateral plantar nerve.11 The current authors did section the most medial expansion of the plantar fascia in every patient and removed two very large heel spurs. Other authors also report sectioning a portion of the plantar fascia and excising large spurs if deemed necessary during nerve release.1, 11, 12 Baxter and Pfeffer1 did not section the plantar fascia in any patient to preserve the windlass mechanism. They did, however, remove any spur that was present. Considering the effect of a plantar fasciotomy on the foot, the authors recommend minimal release followed by postoperative support to minimize any deleterious effects on the midfoot or lateral column.

Conclusion

In the vast majority of patients, heel pain is due to plantar fasciitis and can be treated conservatively. In certain individuals, a neurogenic source of heel pain entrapment of the first branch of the lateral plantar nerve must be considered, especially in recalcitrant cases. Readers are encouraged to examine the medial heel as part of the initial evaluation of patients with heel pain. The long-term results of the surgical release of this nerve with partial plantar fasciotomy have been promising.

References

1. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279: 229, 1992.
2. Arenson DJ, Cosentino GL, Suran SM: The inferior calcaneal nerve. JAPA 70: 552, 1980.
3. Przylucki H, Jones CL: Entrapment neuropathy of muscle branch of the lateral plantar nerve: a cause of heel pain. JAPA 71: 119, 1981.
4. Banks AS: 'Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '94, ed by CA Camasta, NS Vickers, JA Ruch, p 27, The Podiatry Institute, Tucker, GA, 1994.
5. Banks AS: 'Entrapment of the First Branch of the Lateral Plantar Nerve: Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '95, ed by CA Camasta, NS Vickers, JA Ruch, p 159, The Podiatry Institute, Tucker, GA, 1995.
6. Tanz SS: Heel pain. Clin Orthop 28: 169, 1963.
7. Baxter DE, Thigpen CM: Heel pain operative results. Foot Ankle 5: 16, 1984.
8. Hendrix CL, Jolly GP, Garbalosa JG, et al: Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome. J Foot Ankle Surg 37: 273, 1998.
9. Schon LC, Glennon TP, Baxter DE: Heel pain syndrome: electrodiagnostic support for nerve entrapment. Foot Ankle 14: 129, 1993.
10. Henricson AS, Westlin NE: Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve? Am J Sports Med 12: 152, 1984.
11. Kenzora JE: The painful heel syndrome: an entrapment neuropathy. Bull Hosp Jt Dis 47: 178, 1987.
12. Sammarco GJ, Helfrey RB: Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle 17: 520, 1996.
13. Rondhuis JJ, Huson A: The first branch of the lateral plantar nerve and heel pain. Acta Morphol Neerl Scand 24: 269, 1986.
14. Thordarson DB, Kumar PJ, Hedman TP, et al: Effect of partial versus complete plantar fasciotomy on the windlass mechanism. Foot Ankle 18: 16, 1997.


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Tables

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Figures

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Figure 1. A frontal plane representation of the heel depicts the course of the nerve and its site of entrapment. ADQ, adductor digiti quinti; AH, abductor hallucis; FDB, flexor digitorum brevis; QP, quadratus plantae..

Re: cure rates

Joe S on 6/12/02 at 21:58 (087392)

Some doc's out there still don't know about ESWT. That maybe why he hasn't mentioned it yet. It sounds like you have had good care. If you trust your doctor and feel comfortable with him or her then that's half the battle.

Re: The cure rare is a direct quote from the dornier study

Joe S on 6/12/02 at 22:12 (087397)

I would like to see the study. I don't discount the claim. I have looked for the study on their website and could not find it. However, I think that they should have included the patients who had the placebo.

Looking at the ossatron clinical studies they post both the active group and the placebo. They are as follows:

Baseline VAS 12 Week VAS
Active Group 7.7 3.1
Placebo Group 7.9 4.4

I took this from the physician training manual.

For me, I am against fasciotomies as I have seen far too many failures. I can count the number of fasciotomies I have done on one hand in the last three years. That number is 4. I see 30-35 patients in a typical day. I probably see 20-30 patients a week for heel pain. I'm sure you see the same. Maybe more. Most people respond positively to conservative measures.

The only reason I question the validity of the study is that my wife is heavily involved in clinical research (allergy and asthma)and I get tagged along to alot of meetings and see what goes on with 'statistics'.

I guess they don't have that study published anywhere do they?

Re: cure rates

Joe S on 6/12/02 at 22:16 (087400)

ESWT is not without complications either. A very good friend of mine had a patient develop peroneal tendon sheath tears after performing this procedure bilaterally. Any procedure be it an open procedure, a MIS procedure, ESWT, ultrasound, injections, whatever can have an adverse effect. One being RSD. Although rare it can happen with any treatment modality. I don't care what anyone says.

Re: cure rates

Joe S on 6/12/02 at 22:22 (087402)

I totally agree. I would say that 90% or more of all people I see, my partner see's and the other pods in town see do great with the standard conservative measures. It's unfortunate that so many people who don't respond lose some sort of hope. I saw a lady the other day who has been treated for PF by her General Practition for over 8 months with no improvement. He never took an xray. Her pain has been worsening to the point she went to the ER three nights ago. I was the guy on call for that night and saw her in the ER. She had a stress fracture of the calcaneus. Her presenting symptom was not the classic PF presenting symptom either. I mean almost no one who sees and treats heel pain would've thought PF in this woman. I sent her for a bone scan yesterday which confirmed the stress fracture.

Re: re: TONYA, LAURIE, AND DEE

Tonya on 6/12/02 at 22:49 (087406)

Thanks Missy. You've got it right when you say rest is most important. I got brave(a little too brave), and went grocery shopping today. I felt really good walking in, but by the time i got to the check out, i thought i was going to die. I had to come home and ice my foot for quite a while. Guess I learned my lesson.

Re: cure rates

Dr. Zuckerman on 6/13/02 at 05:41 (087418)

Tell me more about the peroneal shealth tears. Was he using ESWT on the personeal tendons. Yes complicatons can occur with any procedure or modality . We are talking about serious complicatons and permanent complicaton,none of which have been seen in the over 250,000 world wide ESWT treatments that have been performed. Speaking of complication. I have seen local steriod injections cause some very long term compications and I have heard of serius burns with physical therapy ultrasound treatment both due to operator use and not modality use. Have you seen RSD with ESWT. Never have read or heard about this. I have studied , investigated ESWT for over five years and still I have heard, read about any serious complications.

Re: Dr. Zuckerman/Dr Ed

john h on 6/13/02 at 10:05 (087445)

I am amazed that the fascia is only 3/4' wide where it attaches to the heel. When doing a fascia release the surgeon must be doing the cutting where it is much wider or else it would be very easy to cut the entire fascia loose from the heel.

Re: cure rates

Dr. Zuckerman on 6/13/02 at 10:44 (087450)

Just my point !!!. So take a good look at ESWT again. The results and lack of serious complications make it the procedure of choice. Yes the insurance hasn't knicked in but you owe it to your patients to inform them about ESWT and yes if you have no interest refer them to a physician that is doing it. Still interested in the peroneal tear from ESWT. Any details that you can tell me. Where do you practice ?

Re: Something else to consider

Tammie on 6/13/02 at 11:27 (087457)

Tonya. Brian is indeed has the inforamation to tell you about how to find care for pain . YOU do not need to live life in pain ! I found a great Pain management Dr. he seems to have done much more for me then most of my dr.s! That is sad but then it is great as he was interested enough to order the tests before we go on . I had the nerve test and the mri, neither which my other dr.s felt were needed! Along with thease tests he gave me scripts for medications to help me threw this period also taking the time to explain to me the good things along with the bad things . Also since I have never ever been a pill taker my fears of addiction and sorts he took time and taught me how to manage the pain and how to know that he will guide me in finding a level of pain relief that will allow me to have some of my life back and maybe with the nerve blocks in time I may not need thease drugs and we can then taper them off. Please think about what Brian offered you as it might be something you could look into ! I am not a drug pusher I really am not but I from my own expierances to this point has been a life savor! Good Luck and hope you find some pain relief somewhere ! Hugs to you , and I am not a dr. I post as a friend!

Re: cure rates

Joe S on 6/13/02 at 19:48 (087507)

I practice in Virginia. My friend who had the peroneal tear problem is in Fl. Basically it was confirmed by MRI. It was a partial tear. I believe he made the patient partial weightbearing in a walking cast. The pain was inferior and lateral along the course of the P.L. tendon. I am certified by Healthtronics. I do believe in ESWT. I do recommend it in those that meet the criteria. Greater than 6 months in duration. We have, as well as Healthtronics have had an extremely hard time getting people approved for the procedure. I am hearing this from everyone else who uses this modality as well. We are looking into other machines such as the Dornier. I know of one individual who is using a 'Storz' machine with fairly good results. However, I don't think that machine is FDA approved for chronic insertional plantar fasciitis. I don't know about you, but most people do not nor will they pay out of their pocket for this treatment or any treatment. They will pay to get their engine rebuilt though.

Re: cure rates

Joe S on 6/13/02 at 19:52 (087509)

No I have never seen RSD with ESWT. However, as with any treatment (Injections, surgery, PT, looking at it the wrong way etc) the chance of RSD is there. Remote as it is. I'm sure someone will develop a problem with this as more and more procedures are done. It's kind of like the EPF. When it first came out, everyone was doing them. Then people started realizing that these don't work any better than the open or semi open procedure. In fact, they may cause more complications than anything else.

Re: The cure rare is a direct quote from the dornier study

Dr. Zuckerman on 6/17/02 at 16:52 (087836)

Give me your fax number and I will fax over the graph of the one year dornier follow up results.

Re: The cure rare is a direct quote from the dornier study

Joe S on 6/17/02 at 18:18 (087841)

Dornier Is actually sending us some material. We are considering them as well. Ossatron / Healthtronics has been a big let down. Not from a treatment standpoint but from getting patients precertified. Thank you though.

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:01 (088247)

Joe:
The reimbursement for ESWT is tight in my area. I often send cash patients on a 2 1/2 hour drive to Vancouver where ESWT is $750 Canadian which is about $535 US. This is a very reasonable cost for the treatment.
Ed

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:04 (088248)

Joe:
We are all frustrated, as practitioners, by the unwillingness of many patients to pay for effective treatments out of pocket. The same patients often do not hesitate to pay far more for their car, stereo equipment, computer gear,e etc.
Ed

Re: Dr. Zuckerman/Dr Ed

Ed Davis, DPM on 6/21/02 at 19:08 (088251)

John:

Your understanding of the rationale for the Baxter procedure seems correct. It is based on Baxter's theory that much heel pain involves entrapment of a branch of the lateral plantar nerve. It is an interseting theory but is in need of more supporting evidence and has a fairly limited number of 'believers.'
Ed

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:12 (088252)

Joe:

I have a friend in Louisiana who prefers the instep procedure. He has performed a number of such procedures on individuals in whom EPF had failed. He is convinced that EPF frequently misses some important medial fibers, perhaps fibers of the fascia that emanate from the medial aspect of the tuberosity but converge more distally and are thus found when doing the instep procedure.
Ed

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:16 (088254)

Joe:

Another reason for surgical failures is failure to address the contribution to pathology from a tight gastrosoleus achilles complex.
I, like others, find success with conservative treatment usually, but of the individuals who do go on to surgery, I perform an achilles lengthening or gastroc recession with about 40 to 50% of plantar fascial releases.
Ed

Re: cure rates

Joe S on 6/23/02 at 17:46 (088347)

I agree. I'm sure you as well as Dr. Z are aware of the amount of time it takes in order to get someone 'precertified'. The amount of time it takes my nurse to get the patient's record copied, put it in an envelope, and sent to Healthtronics takes about an hour. This puts her behind and she has to play catchup. An hour is alot of time. There are several other things she could be doing which would keep the flow of the office going. I've pretty much delegated friday afternoons to getting this (Ossatron Insurance/Medical Record) work done. I just can't afford her taking time away from patient care or other back office duties to do this.

Re: cure rates

john h on 6/24/02 at 09:28 (088364)

That cost is much more than reasonable Dr. Ed. Any guesses what the cost might be once this machine is approved in the U.S. market. What does this machine cost?

Re: 5 WKS POST OP

john h on 6/11/02 at 11:17 (087106)

Good to hear about your positive progress Tonya. Facts are that surgery cures many more people than are made worse. Most of our people on the board are ones who have been made worse. We rarely hear the success stories.

Re: 5 WKS POST OP

Laurie R on 6/11/02 at 11:21 (087108)

Dear Tonya , How wonderful to hear you are doing so very well... I'm also 5 weeks post opp. I had a PF Open release and a TT release and my tendons cleaned out and a groth removed ... I am doing really well also . I am so glad I had the surgery as well....

I like you have a wonderful family , my hubby has been so very great to me . Also my kids have done a great job .. You sound just like me , I also did some laundry the other day and I was so happy to be able to do it . After all these weeks of doing nothing , it feels so good to do a few things ...

Take care and keep us poted and again I am so glad to hear you are doing so well.....

Laurie R

Re: 5 WKS POST OP

Dee on 6/11/02 at 13:28 (087131)

You go girl!! So glad to hear that you are doing excellent!!! It's funny how something as mundane as laundry can actually be exciting isn't it?? I am 1 week and 1 day post op and go to the doc today to have my stitches removed. I too am doing excellent!! Still just putting some weight mostly on my toes, but I can already tell that I am not going to have the severe pain in my heel like I had before my surgery. I can move my foot more now than before and don't have hardly any pain at all when I do. I am still forcing myself to stay as completely off the foot as possible because I tend to be impatient and wanting to walk NOW!!!!! I fully expect my doctor to release me to go back to work next week. Even though I have enjoyed not having to be at work, I am starting to miss it and am actually looking forward to returning. (Did I really say that???) :-)

I just want to thank you and everybody else on these boards for being so encouraging and supporting. I think it's important to let people know that we have been where they may be now and that it can and usually does get better. I know personally that I have learned so much from 'chatting' with you guys on here and that knowledge has eased my fears greatly. I hope you and everybody else continues to improve. Have a pain free wonderful day!!!

Re: 5 WKS POST OP

Tonya on 6/11/02 at 13:46 (087139)

Dee, I'm glad to hear you are doing so well. I have been thinking about you. Just take it slow, slow, slow. Believe me, your foot will let you know what you can and can not do. Even though I can walk on mine, i still am not comfortable driving. The constant pressure is just too much. I hope all goes well with you at the doctor. Although, it was almost three weeks before i had my stitches removed, my doctor cleaned my wound at one week with iodine swabs before casting me. I can tell you that the surgery site was still very sore. As we have all witnessed on this board, we all heal very differently. Seems you and I are some of the lucky few that have had little to no complication. Keep us updated on your continued great progress. Tonya

Re: 5 WKS POST OP

Tonya on 6/11/02 at 13:50 (087140)

Laurie, Listen to us!!!!!:) Two months ago we would have given anything for someone to do our laundry. Isn't it funny the things you enjoy when you've done nothing but sit for over a month. I wish you luck with your healing in the weeks/months ahead.

Re: cure rates

Ed Davis, DPM on 6/11/02 at 19:41 (087190)

John:
You are correct in that surgery works more often than not. The perplexing aspect is the inability to explain why surgery fails in a number of cases and as such, the inability to offer good predictablity of outcomes.
Ed

Re: 5 WKS POST OP

kay f on 6/11/02 at 20:02 (087193)

i'm so happy to hear you are doing so well. my surgery is next tuesday and i am looking forward to having some relief in my pain. i'm thinking positive here. i went to see my family doctor today and he prescribed me some antidepressants so i think once i get them going in my system i will feel better mentally. i've never had to deal with depression before. i was so embarrassed i nearly started crying while talking to the doctor.
but anyway i want you to keep us updated. i will be right behind you in your progress i hope.
thanks for posting
kay

Re: 5 WKS POST OP

kay f on 6/11/02 at 20:04 (087196)

laurie thanks for your post also. it really helps people who have to have surgery and are scared it won't work. i've been through everything with this p.f. and i am ready for some good news.
kay

Re: cure rates

Joe S on 6/11/02 at 20:16 (087200)

I believe much of the failure of the surgery is due to an improper diagnosis. Also, when performing an open plantar fasciotomy, you still can't actually see the plantar fascia (unless you do an instep plantar fasciotomy). With this being said, some surgeons just cut away at something in the medial aspect of the heel thinking that they got the plantar fascia. I see it periodically. I've done it as well. The one thing I listen for after I clamp the plantar fascia, is a crunching sound when I cut the plantar fascia with a heavy scissor. Typically sounds like celery crunching. This is done under tension in order to assess the medial band of the plantar fascia being cut. I saw a lady today who had a post op incisional neuroma overlying after a plantar fasciotomy. Thankfully, it was not done by me. Anyway, most people are much better after surgery than are worse.

Re: cure rates

DR Zuckerman on 6/11/02 at 20:35 (087202)

One of the major reasons for failure of plantar fascia surgery is due to cutting a structure that was never suppose to be cut in the first place. Another reason is that you should only do pf releases for heel spur syndrome and no other reason in a heel pain patient. If you cut the plantar fascia in a patient that has no first step morning pain you are could have additional pain and foot problems. As podiatrist we talk about biomechanics and how important bimechanics are then we go ahead and cut a very important biomechanical structures .Makes no sense to me.

There is so much degenerative joint disease in the foot from pf releases down the road. Most physicians either don't recognize this or treat this as a new problem. Yes there are alot of pain free results but the idea to cut the fascia makes no sense to me.

Re: Kay

Tonya on 6/11/02 at 20:42 (087203)

Kay, Thinking positive is exactly what you should be doing. Don't be embarrassed about the antidepressants. If that is what you need in order to make it through the day, then so be it. I've said it before, constant daily pain can wear you down. It could make the most positive of people depressed. I hope that all goes well with you. If you ever need anyone to talk to outside of the board, please email me. The address is (email removed). You always have shoulders here on the board too. We've all been through it. I will be out of town the 18th to 23rd of June, but will occassionaly check my mail. Regardless, keep us updated. God Bless. Tonya

Re: cure rates

Tonya on 6/11/02 at 21:03 (087207)

Dr Zuckerman, It seems from this response and a few other responses that I have read of yours that you are not very keen on the fascia release.I had the instep fascia release. I did not know there was a difference between and open and instep fascia release. I just looked at my discharge papers and it says instep fascia release. If you are presented plantar fasciitis symptoms from a patient, how do you treat them? I do believe that you recommend ESWT, but what if we either cannot afford it, or our insurance will not cover it. I am talking about a patient who has exhausted all conservative therapies. Please do not think that I am challenging your knowledge, because I am genuinely asking. My husband is in the military and since I am not the soldier, there is only so much they will approve regarding my treatment. I am very pleased with my surgery on my right foot, but am looking at surgery on my left too. If surgery could be eliminated on my left, I would be thrilled. If there is another treatment out there somewhere that I could ask my doctor about, I would. I just do not know of any. In case you have not read my past posts. I have already been through tapings, strappings, iceing, stretching, cortizon injections(twice in each foot), orthotics, night splints, and physical therapy. Although, i do not remember the exact name of the modality that I had done, I can describe them. The took little pads with electrodes on them. On one pad they saturated it with a medicine and applied it to the tendon area, and applied one to my inner calf. This was done to both feet at the same time. They hooked what looked like little jumper cables up to each of the pads. They said that electric current would push the medicine into the tissue. I had ten of these treatments on each foot. My last treatment was the friday before my surgery. It took a bit of the pain away immediatly after the treatments, but I did not experience any real relief. Any input you can give me would be appreciated.

Re: cure rates

DR Zuckerman on 6/11/02 at 21:38 (087212)

Hi

If all fails and ESWT isn't a logical treatment for you I would then do Miminal incision plantar releases. I do this procedure thru the bottom. It has proved tobe very effective in my hands however complications do come up and in very rare cases pain that is permenent.

Re: cure rates

Joe S on 6/11/02 at 23:08 (087219)

In a perfect world, no structure should ever be cut. We don't live in a perfect world however. I don't recommend plantar fascial releases hardly at all. Only as a last resort. I also don't recommend ESWT as a primary procedure. If all conservative measures fail then these two alternatives exsit. Those with the resources undergo ESWT and those without whose insurance will not cover it have three options. Take out a loan for ESWT, have surgery (by wharever means), or live with the pain.

Re: cure rates

Tonya on 6/11/02 at 23:16 (087220)

Thanks for the advice. Actually, what you recommended is what I believe I had done. I had said on my discharge papers the nurse had written that I had an instep release, but I think she was mistaken(now that's comforting). That would be towards the side of my foot, right? What I have is a small incision(that took 5 stitches)in the shape of a cresent moon. Again, thanks for the info.

Re: cure rates

Tonya on 6/11/02 at 23:19 (087221)

Unfortunately, I don't believe I have what it takes to live with the pain. Nor the means to take on a loan, so I guess I have to take what is being offered, and pray all goes well.

Re: cure rates

Joe S on 6/11/02 at 23:19 (087222)

You had iontophoresis. Basically, the difference between an instep plantar fasciotomy is that the incision is made more in the arch. You can actually see how much of the plantar fascia you are cutting. The incision is somewhat larger than the traditional open or semiclosed incision. The success rates are about the same. There is one source that you can go to and do a literature search on the various heel spur surgery techniques. http://www.abps.org (the American Board of Podiatric Surgery), http://www.apma.org . You can do a literature search under their journal articles for basically any type of surgical procedure.

Re: re: TONYA, LAURIE, AND DEE

Missy B on 6/11/02 at 23:24 (087223)

How wonderful to hear encouraging news from all of you. It sounds as if each of you is experiencing some positive results of your surgery. Just remember that REST is still important in the weeks and months ahead, so try not to overdo it as you begin to feel better.
Today, I am 5 months post PF/TT release and am holding at what I consider to be an 80% improvement over my pre-surgery pain. I say 80% because although the pain and numbness associated with the TT entrapment has completely disappeared, I still have some residual PF soreness. However, I got my new custom orthotics yesterday, so my pod and I are hoping that these, along with continued stretching exercises and some icing, will relieve most, if not all, of the PF soreness in the months to come.
At least now I can get thru my day at the hospital with a smile on my face instead of tears in my eyes.
I hope you all continue to improve in the days and weeks ahead - please keep us posted. I will be thinking of you and wishing you the best.
Missy B.

Re: cure rates

Joe S on 6/11/02 at 23:26 (087224)

Tonya, I just posted a couple of websites that you maybe able to find some more info on long term cure rates for different plantar fascial releases. Someone is stating on this board that 100% of all subject who underwent ESWT by a certain machine had 92% relief. This is not accurate. In a true, double blinded, scientific study, there are going to be positive outcomes and negative outcomes in both groups. If the study includes only one treatment protocol and the examiner is reporting a certain success rate then there is no validity to the study. Some people who get the placebo will respond positively to treatment when in effect no treatment was ever rendered. I take it that you're other foot is doing ok after the instep fasciotomy. If so, then why not opt that again on the one that is now hurting? ESWT is not the end all cure all to heel pain. What if you spent a few grand and were no better? Then you'd be out of money and still would have a painful foot.

Re: cure rates

Joe S on 6/11/02 at 23:28 (087225)

The MIS procedure is directly on the bottom of your foot. An area prone to painful thick, hypertrophic scarring.

Re: cure rates

Tonya on 6/12/02 at 00:54 (087232)

Joe, I plan on having the same procedure on the left(and yes, my right foot is doing wonderfully). I have just caught on that there are a few doctors and patients that post on here that are totally against a fascia release. I was just curious as to what they would recommend if they are so against it. To be truthful, until reading posts on this board, i had never heard of ESWT. Again, my husband is in the Army and there is only so much that Tricare(military med. coverage) will pay for. I am very comfortable with my doctors ability to give me the best care that he is allowed by the Army, and since he never mentioned ESWT, I assume that it is not an option for me. Lord knows he had me doing everything else. He was very strict about even contemplating surgery until all conservative therapy was exhausted with me. I was asking DR.Zuckerman if ESWT is not an option and conventional therapy is exhausted, what he would recommend to a patient such as myself if he was totally against a fascia release. I am always open to any advice I can get. Whether be it by another doc or another patient. Having you guys respond to me has a) allowed me to be confident about my surgery decision and b)shown me that my doctor has given me the best care he can. Let me tell you, at least on the Army base we are on, a doctor that will take the time to speak to you past 15 min. is rare. Maybe it's because he is a specialty doctor, i don't know. You hit the nail by pointing out that not all of these posts are accurate. Which just proves that all of us as patients or potential patients must research everything we are being told. Again, I thank everyone who posts on here,whether you be a doctor or a patient. I'll be sure to look up the websites you noted. As for spending a couple of grand....unfortunately, on an E-4 pay with three kids, I don't even have 1/2 a grand to spend. So, I have to take what is recommended by my doctor, and hope for the best. Thanks for the info.

Re: The cure rare is a direct quote from the dornier study

DR Zuckerman on 6/12/02 at 01:24 (087233)

Dear Joe S DPM

It was Dr.Z who stated that the in a one year follow up with the dornier epos ultra those who underwent treatment has a 92% reduction in pain. This is a direct quote from the one year follow of the FDA study In addition the average VAS score was 0.6 . The pre- treatment VAS score was 7.7. I only quote from the study.

The standard for recommendation for ESWT is the pain should have pain for at least six months and failed conservative treatment. It isn't ever used as a primary procedure.

The above study EXCLUDED the placebo group and only included the treated patients.

Patient do have options and so long as they realize that with plantar fascia releases you stand the option of a foot worse off then before which hs nothing to do with a Wrong diagnoses then go for it

Over the past twenty two years I have seen just too many pf releases in patients that are will never walk again.

Re: cure rates

DR Zuckerman on 6/12/02 at 01:33 (087235)

just curious have you ever seen an mis procedure with the incision on the bottom of the foot?. Have you even seen a medial incision from a open release with a painful hypertropic scar ?

I have seen quite a few open release done from the side with nerve pain, hypertrophic incision and in some cases keloid.

I am only talking about incisions.

Re: cure rates

john h on 6/12/02 at 10:18 (087286)

Dr. Ed: Dr. Gordon in Canada said to me that there is a percentage of people that just are not going to be cured no matter what you do. That is not good to hear but probably is on the mark. However, we all should approach this with the thought we are not one of those. I think all pilots in combat develop a mentality that they will never be the one to be shot down inspite of the fact that statistically they may have a 30% chance of being shot down. We lost over 6000 helicopters in Vietnam. Sure glad I did not know those numbers when I was flying them. I was one of the 6000.

Re: cure rates

john h on 6/12/02 at 10:24 (087291)

Tonya: You mention discharge papers and your eamail begins with 'paratrooper'. Were you a paratrooper? A couple of years ago I corresponded with a paratrooper at Ft Bragg who had terrible foot problems. He had surgery on his achilles and a cheilectory. Last word I had from him he was back to jumping and doing great.

Re: cure rates

Tonya on 6/12/02 at 10:32 (087295)

John, I was meaning my hospital discharge papers from when I had the surgery done. My husband is the paratrooper, because I see no need to jump out of a perfectly good airplane. I am just an ordinary Army housewife. We live on Fort Bragg, and I think that I live in 'Bad Foot Country'.

Re: Dr. Zuckerman/Dr Ed

john h on 6/12/02 at 10:32 (087296)

Dr. Zuckerman/Dr Ed: As you know I had the Baxter Procedure performed on my left foot. The more I think about this the more I think it is not really a PF release. A 1/2' semicircle wedge of fascia is removed from over the Baxter Nerve at a point near where the fascia attaches to the heel on the inside of the foot. Basically if you are only cutting 1/2' of fascia I assume that is no more than 15% of the width of the fascia so you have a very minimal release which is why your foot integrity remains very much the same. Obviously even a 10-15% release releaves some stress on the fascia but I guess the primary thinking with this procedure is to reduce any pressure on the Baxter Nerve and any release is just secondary outcome? Am I right or wrong in this thinking?

Re: cure rates

john h on 6/12/02 at 10:38 (087299)

Joe: In my readings I find that 90% of all the reported PF cases each year (3 mil - 6 mil)are cured with the standard conservative meaures so it seems clear that what ever you guys are doing works for the vast majority of the people. The folks on this board are part of the other 10% and I would guess most of us have tried every conservative measure and then some.

Re: cure rates

john h on 6/12/02 at 10:45 (087301)

Most of the nmbers I see Joe are for a success rate of 70-80%. Success being defined by many as a 50% reduction in pain. Lots of numbers out there from different sources. Some of the German stats are based on a very large base. Bayshore has been in the business a long time and I tend to think their stats are worth considering when making a decision. When you are in as much pain as many on this board you tend forget about statistics and the scientific method and will try most anything. This includes me.

Re: cure rates

john h on 6/12/02 at 10:47 (087302)

Joe: Is MIS always from the bottom of the foot? I thought i have seen 1-2 stitch procedures that were on the edge and curved to the bottom.

Re: Dr. Zuckerman/Dr Ed

scott r on 6/12/02 at 10:47 (087303)

John, the fascia is about 3/4' wide where it attaches to the heel. The baxter proc is meant to releave nerve problems but also relases some of the fascia

Re: cure rates

john h on 6/12/02 at 11:01 (087305)

I had much rather spend $3000 or more dollars on ESWT knowing there was virtually little risk of being made much worse.If that did not work then surgery would be my next alternative. My first question and commments to my surgeon were (1) what are the chances this will make me worse (2) what are the chances this will make be better? I told him I could live with the possibility it would not work but did not want to end up like some of our people with failed surgeries. Even with ESWT if it works great if it fails and I am no worse I have lost some money but still have hope and not possible made worse for life, Once that fascia is cut there is no turning back.

I am not against surgery. I had it! I did choose the Baxter Procedure because it seemed like the procedure with the least likely chance of being made worse. Possible a MIS might have given me a better chance for a cure but I was more concerned with being made worse. Many doctors will not perfom PF surgery under any circumstances.

As I know, a lot more people have successful surgeries than failed ones so surgery will be with us for the forseeable future as it should be.

Re: Something else to consider

BrianG on 6/12/02 at 20:47 (087368)

Hi Tonya,

There is one more possible treatment to consider. If you don't feel comfertable with surgery at this point, you may be able to put everything off for a few years by seeing a pain management specialist. They will prescribe enough pain meds so that you can buy some more time. No telling what new, or refined treatments may be available in the next few years. Check out this web site if you are interested, it's a start: http://www.pain.com

Good luck
BrianG

Re: cure rates

Joe S on 6/12/02 at 21:40 (087381)

Actually, I saw your video that you posted. It looked like a plantar approach to me. And, it still appears to be a blind procedure. I have seen a painful hypertrophic scar from a medial incision as well. I booked an excision of a this hypertrophic scar just yesterday. I have also seen patient's who have had these MIS 'surgeons' 'decompress' the calcaneus with drill holes and go on to a calcaneal fracture and develop horrible STJ arthritis that requires a triple arthrodesis. Yes I have seen it. I have seen post op cases where a surgeon does both a plantar fasciotomy as well as a tarsal tunnel release in which both have gone onto failure and the development of RSD. No one wants this complication irregardless of the procedure of choice.

Re: cure rates

Joe S on 6/12/02 at 21:48 (087386)

No MIS is not always from the bottom of the foot. As far as heel spur surgery goes, there are a couple of medial approaches. You can take a nonweighbearing xray (lateral view), measure the distance from the posterior aspect of the heel and the inferior most aspect of the heel. These two lines can be intersected at the medial calcaneal tubercle (insertion of the plantar fascia) or where the actual spur is. From this measurement, you can dictate where your incision is. 9/10 times this puts you right on the money. All you need to do is a small 2cm incision. This is somewhat bigger than the incision for the EPF and quite a bit smaller than the incision for the Instep Plantar Fasciotomy. There are many good MIS procedures out there. An EPF could be considered a MIS procedure just by the size of the incision alone. I did an ankle arthroscopy today which technically you could consider a MIS procedure until I opened up her lateral ankle and repaired her anterior talofibular ligament.

Re: Dr. Zuckerman/Dr Ed

Joe S on 6/12/02 at 21:54 (087388)

There is an article by Alan Banks, a podiatrist from Atlanta Georgia who is also the residency director of probably the most well known and most well respected podiatric surgical residency in the U.S. I posted this article some time ago and it discusses this procedure in detail. The incisional approach for this procedure is different from a 'typical' heel spur incision. http://www.apma.org is were the article is at. Actually, here it is:

--------------------------------------------------------------------------------
Analysis of Release of the First Branch of the
Lateral Plantar Nerve

JAPMA VOLUME 90 / NUMBER 6 / JUNE 2000

Robert M. Goecker, DPM*
Alan S. Banks, DPM†

*Submitted during third-year residency, Northlake Regional Medical Center, Tucker, GA. Mailing address:1961 Floyd St, Ste C, Sarasota, FL 34239.

† Member, The Podiatry Institute, Tucker, GA; Director of Residency Training, Northlake Regional Medical Center, Tucker, GA.

--------------------------------------------------------------------------------

The authors conducted a retrospective study of the release of the first branch of the lateral plantar nerve in the treatment of chronic heel pain unrelieved by conservative treatment modalities. A total of 17 patients (18 feet) were evaluated following external neurolysis for heel pain caused by entrapment of the first branch of the lateral plantar nerve. The average postoperative follow-up time was 32.8 months, with a range of 10 to 72 months. Every patient deemed the surgery successful. At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. There was one postoperative complication, medial calcaneal nerve entrapment; it was successfully treated with neurectomy. (J Am Podiatr Med Assoc 90(6): 281-286, 2000)

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Plantar heel pain is usually attributed to plantar fasciitis or heel spur syndrome. In certain individuals, however, a different entity can produce similar pain and symptoms. Several authors have described a neurogenic source of heel pain: entrapment of the first branch of the lateral plantar nerve.1-12

The first branch of the lateral plantar nerve is a mixed nerve with both motor and sensory fibers. Muscles supplied by this nerve include the abductor digiti minimi, flexor digitorum brevis, and quadratus plantae. Sensory fibers supply the calcaneal periosteum, the long plantar ligament, and the skin at the plantar lateral aspect of the foot. This branch originates from the lateral plantar nerve proximal to the abductor hallucis and then dives through the fascia at the superior margin of the abductor. The nerve courses distally between the abductor hallucis muscle and the medial edge of the quadratus plantae until it reaches the inferior margin of the abductor fascia. There it turns laterally between the flexor digitorum brevis and the quadratus plantae.1 The nerve at this point lies adjacent to the calcaneus approximately 0.5 cm distal to the medial tubercle of the calcaneus.2, 3 Failure of traditional heel spur surgery may be due to damage and subsequent entrapment of the first branch of the lateral plantar nerve or an inadequate release of a primary neurogenic source of heel pain. Obviously, the nerve is not released through the traditional open heel spur surgical approach. This nerve branch should not be confused with the medial calcaneal nerve, a purely sensory nerve that lies in the superficial fascia of the heel.4, 5

In 1963, Tanz6 proposed the first branch of the lateral plantar nerve as an overlooked source of plantar heel pain, and he demonstrated the nerve's anatomy from cadaveric dissection. However, it was not until 1981 that Przylucki and Jones3 correlated actual patient symptoms with this structure. Their surgical treatment for this condition consisted of excision of the nerve. Subsequently, other authors reported successful treatment of this type of chronic heel pain with external neurolysis rather than nerve excision.1, 4, 5, 7, 8, 10-12

Baxter and Thigpen7 in 1984 described two possible sites of entrapment. The first is the sharp fascial edge of the abductor hallucis muscle where the nerve changes course and turns laterally. Another possible site is the medial ridge of the calcaneus where the nerve passes beneath the tuberosity and origin of the flexor digitorum brevis and the plantar fascia. Therefore, nerve impingement may be caused by an increase in mass, such as a calcaneal spur, within the flexor digitorum brevis. Rondhuis and Huson13 concluded that the exact site of the entrapment is where the nerve passes between the taut deep fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle (Fig. 1). Pronation, muscle hypertrophy, or other sources of irritation have been cited as instigating events that may irritate the nerve as it passes through the fascial port of the abductor hallucis.

Patients with heel pain secondary to nerve entrapment may present with slightly different symptoms than individuals suffering from plantar fasciitis. In the former condition, the pain is usually not as great in the morning or after periods of rest, but seems to be more pronounced after activity. Przylucki and Jones3 noted that compression of the first branch of the lateral plantar nerve may occur by physiologic motion secondary to pronatory forces. As the foot is pronating, the tension of the fascial structures increases, resulting in compression of the nerve. This suggests that the nerve compression may be not only static (constant) but also dynamic and can worsen with pathologic gait patterns.

However, in some patients a history more similar to that associated with plantar fasciitis may be described. Chronic inflammation of the plantar fascia may coexist with, and possibly predispose to, entrapment of the first branch of the lateral plantar nerve.4, 5 Therefore, the patient may initially have some component of plantar medial heel pain as well. In such cases, the plantar fascial symptoms will tend to respond to the conservative modalities, but the symptoms related to the nerve entrapment may tend to persist. In some instances, the patient may complain of pain radiating toward the lateral aspect of the heel following the normal anatomical course of the nerve. There may be associated motor weakness of the abductor digiti minimi indicated by the patient's inability to abduct the fifth toe (Fig. 2). Abduction of the fifth toe may be a difficult task for many people to perform, but in some individuals with this entrapment, a difference may be observed between the symptomatic and asymptomatic sides.

Regardless of the history, the diagnosis of entrapment of the first branch of the lateral plantar nerve may be made during the clinical examination. The exact source of the patient's symptoms may be determined by careful palpation of the plantar aspect of the heel. Clinically, the pathognomonic sign of this entity is greater pain with compression over the medial aspect of the heel than plantarly (Fig. 3). Hendrix et al8 labeled this test the nerve compression test. Palpation in this region pinches the nerve between the deep fascia of the abductor hallucis and medial caudal margin of the quadratus plantae, resulting in pain and possible paresthesia.1 Hendrix et al8 have also found that plantarflexion and inversion of the foot (Phalen's maneuver) may be helpful in diagnosing entrapment of the terminal branches of the tarsal tunnel, including the first branch of the lateral plantar nerve. This movement reduces the width of the porta pedis and causes the superior margin of the abductor hallucis to compress the nerve, producing nerve impingement signs and symptoms. The nerve is also felt to be compressed at the exit site of the fascia between the abductor and flexor brevis.4, 5

The role of other diagnostic tests, such as electromyography and nerve conduction velocities, has been described by Schon et al.9 They found electrophysiologic abnormalities in 23 of 38 symptomatic heels, although careful review reveals that abnormalities in the lateral plantar nerve were found in only 7 patients (16%). It is also worth noting that the first branch of the lateral plantar nerve is technically difficult to isolate. It must therefore be emphasized that diagnostic tests are not a substitute for good clinical evaluation. If one does not trust a clinical diagnosis of nerve entrapment, technetium bone scans and magnetic resonance imaging (MRI) evaluations can be used to rule out an inflammatory source of heel pain. In the first few cases evaluated by the authors, patients underwent technetium bone scans and MRI evaluations, both of which failed to demonstrate inflammatory change in the heel area. This suggests that in these patients the pain is more consistent with nerve entrapment. Therefore, simple release of the plantar fascia will have limited effects on the symptoms.

The purpose of this article is to report on the success and long-term efficacy of release of the first branch of the lateral plantar nerve in those patients who failed to respond to conservative treatment modalities.

Materials and Methods

A total of 17 patients (18 feet) with painful medial heel pain were first treated with conservative modalities, such as padding, strapping, orthoses, various forms of immobilization, cortisone injections, and diagnostic nerve blocks. All patients had received extensive conservative treatment. Some of the patients had received conservative care by other physicians prior to surgical intervention by the authors. Anyone with prior heel surgery was excluded from the study. In each of these cases, the diagnosis of nerve entrapment was based on a positive clinical history and physical diagnostic findings consistent with entrapment of the first branch of the lateral plantar nerve. No other diagnostic modalities are necessary or routinely used by the authors for this condition. Surgery was elected in recalcitrant cases. The surgeries included in the study were performed over a 5-year period. All patients' charts were reviewed, and each patient was evaluated by means of a follow-up examination or a telephone interview. The outcome of the procedures was assessed by means of a questionnaire (Fig. 4).

The surgical technique that was used consists of an oblique incision made over the medial aspect of the heel overlying the course of the first branch of the lateral plantar nerve. The distal extent of the incision ends just beyond the junction of the calcaneal tuber and the plantar fascia. When the incision is oriented in this manner, it remains relatively parallel to the branches of the medial calcaneal nerve; this creates less potential for postoperative entrapment of these structures (Fig. 5).

Dissection is carried through the subcutaneous tissue until the deep fascia over the abductor hallucis can be identified. The superficial fascia is then bluntly separated anteriorly and posteriorly so that the abductor fascia may be clearly visualized. A carefully controlled inverted T-incision is then made, with the horizontal component of the T beginning at the inferior margin of the deep fascia overlying the abductor hallucis muscle. The vertical incision is then made extending proximally from the middle of the horizontal arm to the superior aspect of the abductor hallucis muscle belly. The muscle belly of the abductor is freed from the fascia at the superior margin and retracted inferiorly, exposing the fascia separating the abductor hallucis from the quadratus plantae. A vertical incision is then made through this deeper fascial layer, and a segment of tissue is removed. This should eliminate any constriction of the first branch of the lateral plantar nerve. As the nerve may also be compressed at the inferior edge of the abductor muscle, this fascia deep to the abductor hallucis muscle belly is vertically sectioned as far inferiorly as possible. The abductor muscle is retracted superiorly, and any remaining intermuscular fascia between the abductor and flexor digitorum brevis is sectioned. This circumferentially releases the fascia around the abductor hallucis muscle belly.

Next, a small portion (approximately one-quarter) of the medial aspect of the plantar fascia is sectioned to completely free the abductor hallucis and eliminate any potential irritation at this level. However, the windlass effect of the plantar fascia is maintained. Sometimes, if it is deemed necessary, an inferior calcaneal spur is gently removed with hand instruments. A Freer elevator is usually placed over the spur to prevent damage to the soft tissues and nerve at this level.

Following surgery, the patient is kept nonweightbearing for 3 weeks. A cast or posterior splint, as opposed to a soft bandage alone, has worked well. It is felt that maintaining the foot in a neutral position prevents coaptation of the incised fascial tissues.

Orthotic support is reinstituted following surgery, especially in patients in whom the plantar fascia is partially sectioned. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and the lateral column. Pain or discomfort in this region was noted postoperatively, despite significant improvement in the heel. This generalized cramping, achiness, and midfoot pain tends to resolve over time and is effectively treated with biomechanical support.

Results

Seventeen patients (18 feet) who had undergone release of the first branch of the lateral plantar nerve using the previously described technique were available for follow-up clinical or telephone evaluation. The average duration of heel pain prior to surgery was 21.2 months, with a range of 6 to 120 months. The time elapsed since surgery ranged from 10 to 72 months, with an average postoperative follow-up time of 32.8 months. Every patient deemed the surgery successful. On a pain scale of 0 to 4, all patients were asked to rate their pain both preoperatively and postoperatively (Table 1). At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. The average preoperative heel pain rating was 3.67, and the average postoperative pain rating was 0.5. A paired t-test was performed on the pain level data, revealing a statistically significant difference to a level of P< .001. There was one postoperative complication, medial calcaneal nerve entrapment, which was successfully treated with neurectomy. This patient is currently asymptomatic.

Three patients complained of a dull pain and a feeling of weakness across the top of the foot between 5 and 10 months postoperatively. Symptoms in this area can probably be attributed to the 'settling phenomenon' that occurs after partial plantar fasciotomy. Thordarson et al14 showed a progressive loss of the arch-supporting function of the plantar fascia as the fascia was sequentially sectioned from medial to lateral. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and subsequent pain.

Two patients also experienced vague lateral column pain. Both of these events were transient. In order to protect the midfoot and lateral column from increased stress after plantar fasciotomy, the authors section only the most medial expansion of the plantar fascia and suggest the use of postoperative orthoses.

Discussion

The vast majority of patients suffering from heel pain achieve symptomatic relief with conservative measures. However, it is important to remain aware of sources of heel pain other than plantar fasciitis. Although reports of neurogenic heel pain have been linked to medial calcaneal nerve entrapment, tarsal tunnel syndrome, and heel neuromas, recent literature suggests that entrapment of the mixed (motor and sensory) nerve to the abductor digiti minimi may be a common source of medial heel pain.1-12 Histologic examination of the nerve branches that have been excised under the described intermuscular septum between the abductor hallucis and quadratus plantae revealed evidence of hypertrophy, perineural fibrosis, increased endoneural collagen, and loss of myelinated fibers consistent with nerve entrapment.1, 3, 7

Once a diagnosis of nerve entrapment is made, conservative treatment modalities similar to those used for plantar fasciitis are instituted. However, it is the authors' experience that these patients demonstrate a less positive response to conservative and supportive treatment modalities. In these cases, a surgical approach that deals with potential nerve entrapment is employed.

As with any procedure, surgical approaches vary and have been adapted over time. Przylucki and Jones3 first described surgical management of this condition. Their approach involved removal of the calcaneal exostosis, plantar fasciotomy, and excision of the muscular branch of the lateral plantar nerve to the abductor digiti minimi. The procedure was performed in only three cases, and the incision placement and exact technique were not discussed.

Baxter and Thigpen7 performed the first large retrospective study of neurolysis of the first branch of the lateral plantar nerve. They performed the procedure on 34 heels using a modified DuVries heel spur incision. They recommended releasing the deep fascia of the abductor hallucis muscle and, if necessary, sectioning a small portion of plantar fascia as well as excising a small portion of a plantar heel spur, decompressing the nerve. They also noted that complete plantar fascial releases and heel spur resection should be avoided.

Henricson and Westlin10 performed the neurolysis through an oblique curved incision extending from below the medial malleolus toward the medial anterior edge of the heel pad. Kenzora11 used a plantar midline incision. These two techniques were used to avoid complications of medial calcaneal nerve injury secondary to the DuVries incision.

Baxter and Pfeffer1 published the results of a retrospective study involving 69 feet that underwent neurolysis. The incisional approach was modified to an oblique vertical incision over the medial heel similar to that described by Henricson and Westlin.10 This incision parallels the course of the nerve and is less likely to injure the medial calcaneal nerve. However, Baxter and Pfeffer still reported two medial calcaneal nerve entrapments with their new incision. The authors, as well as Sammarco and Helfrey,12 have also used the oblique vertical medial heel incision successfully. Even with this incision, extreme caution must be employed at the superior aspect of the incision to avoid injury to the medial calcaneal nerve branch. In the authors' review of 18 surgical procedures, one patient did experience a medial calcaneal nerve entrapment, which was successfully treated with nerve excision.

Recently, Hendrix et al8 proposed a transverse medial oblique approach that allowed them to decompress not only the first branch of the lateral plantar nerve but also the posterior tibial, medial plantar, and lateral plantar nerves. They released the terminal branches of the posterior tibial nerve because of their belief that the chronic heel pain is related to distal tarsal tunnel syndrome. The authors of the present article believe that it is not necessary to decompress the other distal branches of the posterior tibial nerve (tarsal tunnel release) concomitantly with the first branch of the lateral plantar nerve, especially when a limited incision is used for exposure and release.

Finally, one must consider the possibility of plantar fasciitis or heel spur syndrome coexisting with the nerve entrapment. Chronic inflammation from plantar fasciitis and large calcaneal spurs have been linked etiologically to entrapment of the first branch of the lateral plantar nerve.11 The current authors did section the most medial expansion of the plantar fascia in every patient and removed two very large heel spurs. Other authors also report sectioning a portion of the plantar fascia and excising large spurs if deemed necessary during nerve release.1, 11, 12 Baxter and Pfeffer1 did not section the plantar fascia in any patient to preserve the windlass mechanism. They did, however, remove any spur that was present. Considering the effect of a plantar fasciotomy on the foot, the authors recommend minimal release followed by postoperative support to minimize any deleterious effects on the midfoot or lateral column.

Conclusion

In the vast majority of patients, heel pain is due to plantar fasciitis and can be treated conservatively. In certain individuals, a neurogenic source of heel pain entrapment of the first branch of the lateral plantar nerve must be considered, especially in recalcitrant cases. Readers are encouraged to examine the medial heel as part of the initial evaluation of patients with heel pain. The long-term results of the surgical release of this nerve with partial plantar fasciotomy have been promising.

References

1. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279: 229, 1992.
2. Arenson DJ, Cosentino GL, Suran SM: The inferior calcaneal nerve. JAPA 70: 552, 1980.
3. Przylucki H, Jones CL: Entrapment neuropathy of muscle branch of the lateral plantar nerve: a cause of heel pain. JAPA 71: 119, 1981.
4. Banks AS: 'Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '94, ed by CA Camasta, NS Vickers, JA Ruch, p 27, The Podiatry Institute, Tucker, GA, 1994.
5. Banks AS: 'Entrapment of the First Branch of the Lateral Plantar Nerve: Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '95, ed by CA Camasta, NS Vickers, JA Ruch, p 159, The Podiatry Institute, Tucker, GA, 1995.
6. Tanz SS: Heel pain. Clin Orthop 28: 169, 1963.
7. Baxter DE, Thigpen CM: Heel pain operative results. Foot Ankle 5: 16, 1984.
8. Hendrix CL, Jolly GP, Garbalosa JG, et al: Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome. J Foot Ankle Surg 37: 273, 1998.
9. Schon LC, Glennon TP, Baxter DE: Heel pain syndrome: electrodiagnostic support for nerve entrapment. Foot Ankle 14: 129, 1993.
10. Henricson AS, Westlin NE: Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve? Am J Sports Med 12: 152, 1984.
11. Kenzora JE: The painful heel syndrome: an entrapment neuropathy. Bull Hosp Jt Dis 47: 178, 1987.
12. Sammarco GJ, Helfrey RB: Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle 17: 520, 1996.
13. Rondhuis JJ, Huson A: The first branch of the lateral plantar nerve and heel pain. Acta Morphol Neerl Scand 24: 269, 1986.
14. Thordarson DB, Kumar PJ, Hedman TP, et al: Effect of partial versus complete plantar fasciotomy on the windlass mechanism. Foot Ankle 18: 16, 1997.


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Figures

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Figure 1. A frontal plane representation of the heel depicts the course of the nerve and its site of entrapment. ADQ, adductor digiti quinti; AH, abductor hallucis; FDB, flexor digitorum brevis; QP, quadratus plantae..

Re: cure rates

Joe S on 6/12/02 at 21:58 (087392)

Some doc's out there still don't know about ESWT. That maybe why he hasn't mentioned it yet. It sounds like you have had good care. If you trust your doctor and feel comfortable with him or her then that's half the battle.

Re: The cure rare is a direct quote from the dornier study

Joe S on 6/12/02 at 22:12 (087397)

I would like to see the study. I don't discount the claim. I have looked for the study on their website and could not find it. However, I think that they should have included the patients who had the placebo.

Looking at the ossatron clinical studies they post both the active group and the placebo. They are as follows:

Baseline VAS 12 Week VAS
Active Group 7.7 3.1
Placebo Group 7.9 4.4

I took this from the physician training manual.

For me, I am against fasciotomies as I have seen far too many failures. I can count the number of fasciotomies I have done on one hand in the last three years. That number is 4. I see 30-35 patients in a typical day. I probably see 20-30 patients a week for heel pain. I'm sure you see the same. Maybe more. Most people respond positively to conservative measures.

The only reason I question the validity of the study is that my wife is heavily involved in clinical research (allergy and asthma)and I get tagged along to alot of meetings and see what goes on with 'statistics'.

I guess they don't have that study published anywhere do they?

Re: cure rates

Joe S on 6/12/02 at 22:16 (087400)

ESWT is not without complications either. A very good friend of mine had a patient develop peroneal tendon sheath tears after performing this procedure bilaterally. Any procedure be it an open procedure, a MIS procedure, ESWT, ultrasound, injections, whatever can have an adverse effect. One being RSD. Although rare it can happen with any treatment modality. I don't care what anyone says.

Re: cure rates

Joe S on 6/12/02 at 22:22 (087402)

I totally agree. I would say that 90% or more of all people I see, my partner see's and the other pods in town see do great with the standard conservative measures. It's unfortunate that so many people who don't respond lose some sort of hope. I saw a lady the other day who has been treated for PF by her General Practition for over 8 months with no improvement. He never took an xray. Her pain has been worsening to the point she went to the ER three nights ago. I was the guy on call for that night and saw her in the ER. She had a stress fracture of the calcaneus. Her presenting symptom was not the classic PF presenting symptom either. I mean almost no one who sees and treats heel pain would've thought PF in this woman. I sent her for a bone scan yesterday which confirmed the stress fracture.

Re: re: TONYA, LAURIE, AND DEE

Tonya on 6/12/02 at 22:49 (087406)

Thanks Missy. You've got it right when you say rest is most important. I got brave(a little too brave), and went grocery shopping today. I felt really good walking in, but by the time i got to the check out, i thought i was going to die. I had to come home and ice my foot for quite a while. Guess I learned my lesson.

Re: cure rates

Dr. Zuckerman on 6/13/02 at 05:41 (087418)

Tell me more about the peroneal shealth tears. Was he using ESWT on the personeal tendons. Yes complicatons can occur with any procedure or modality . We are talking about serious complicatons and permanent complicaton,none of which have been seen in the over 250,000 world wide ESWT treatments that have been performed. Speaking of complication. I have seen local steriod injections cause some very long term compications and I have heard of serius burns with physical therapy ultrasound treatment both due to operator use and not modality use. Have you seen RSD with ESWT. Never have read or heard about this. I have studied , investigated ESWT for over five years and still I have heard, read about any serious complications.

Re: Dr. Zuckerman/Dr Ed

john h on 6/13/02 at 10:05 (087445)

I am amazed that the fascia is only 3/4' wide where it attaches to the heel. When doing a fascia release the surgeon must be doing the cutting where it is much wider or else it would be very easy to cut the entire fascia loose from the heel.

Re: cure rates

Dr. Zuckerman on 6/13/02 at 10:44 (087450)

Just my point !!!. So take a good look at ESWT again. The results and lack of serious complications make it the procedure of choice. Yes the insurance hasn't knicked in but you owe it to your patients to inform them about ESWT and yes if you have no interest refer them to a physician that is doing it. Still interested in the peroneal tear from ESWT. Any details that you can tell me. Where do you practice ?

Re: Something else to consider

Tammie on 6/13/02 at 11:27 (087457)

Tonya. Brian is indeed has the inforamation to tell you about how to find care for pain . YOU do not need to live life in pain ! I found a great Pain management Dr. he seems to have done much more for me then most of my dr.s! That is sad but then it is great as he was interested enough to order the tests before we go on . I had the nerve test and the mri, neither which my other dr.s felt were needed! Along with thease tests he gave me scripts for medications to help me threw this period also taking the time to explain to me the good things along with the bad things . Also since I have never ever been a pill taker my fears of addiction and sorts he took time and taught me how to manage the pain and how to know that he will guide me in finding a level of pain relief that will allow me to have some of my life back and maybe with the nerve blocks in time I may not need thease drugs and we can then taper them off. Please think about what Brian offered you as it might be something you could look into ! I am not a drug pusher I really am not but I from my own expierances to this point has been a life savor! Good Luck and hope you find some pain relief somewhere ! Hugs to you , and I am not a dr. I post as a friend!

Re: cure rates

Joe S on 6/13/02 at 19:48 (087507)

I practice in Virginia. My friend who had the peroneal tear problem is in Fl. Basically it was confirmed by MRI. It was a partial tear. I believe he made the patient partial weightbearing in a walking cast. The pain was inferior and lateral along the course of the P.L. tendon. I am certified by Healthtronics. I do believe in ESWT. I do recommend it in those that meet the criteria. Greater than 6 months in duration. We have, as well as Healthtronics have had an extremely hard time getting people approved for the procedure. I am hearing this from everyone else who uses this modality as well. We are looking into other machines such as the Dornier. I know of one individual who is using a 'Storz' machine with fairly good results. However, I don't think that machine is FDA approved for chronic insertional plantar fasciitis. I don't know about you, but most people do not nor will they pay out of their pocket for this treatment or any treatment. They will pay to get their engine rebuilt though.

Re: cure rates

Joe S on 6/13/02 at 19:52 (087509)

No I have never seen RSD with ESWT. However, as with any treatment (Injections, surgery, PT, looking at it the wrong way etc) the chance of RSD is there. Remote as it is. I'm sure someone will develop a problem with this as more and more procedures are done. It's kind of like the EPF. When it first came out, everyone was doing them. Then people started realizing that these don't work any better than the open or semi open procedure. In fact, they may cause more complications than anything else.

Re: The cure rare is a direct quote from the dornier study

Dr. Zuckerman on 6/17/02 at 16:52 (087836)

Give me your fax number and I will fax over the graph of the one year dornier follow up results.

Re: The cure rare is a direct quote from the dornier study

Joe S on 6/17/02 at 18:18 (087841)

Dornier Is actually sending us some material. We are considering them as well. Ossatron / Healthtronics has been a big let down. Not from a treatment standpoint but from getting patients precertified. Thank you though.

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:01 (088247)

Joe:
The reimbursement for ESWT is tight in my area. I often send cash patients on a 2 1/2 hour drive to Vancouver where ESWT is $750 Canadian which is about $535 US. This is a very reasonable cost for the treatment.
Ed

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:04 (088248)

Joe:
We are all frustrated, as practitioners, by the unwillingness of many patients to pay for effective treatments out of pocket. The same patients often do not hesitate to pay far more for their car, stereo equipment, computer gear,e etc.
Ed

Re: Dr. Zuckerman/Dr Ed

Ed Davis, DPM on 6/21/02 at 19:08 (088251)

John:

Your understanding of the rationale for the Baxter procedure seems correct. It is based on Baxter's theory that much heel pain involves entrapment of a branch of the lateral plantar nerve. It is an interseting theory but is in need of more supporting evidence and has a fairly limited number of 'believers.'
Ed

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:12 (088252)

Joe:

I have a friend in Louisiana who prefers the instep procedure. He has performed a number of such procedures on individuals in whom EPF had failed. He is convinced that EPF frequently misses some important medial fibers, perhaps fibers of the fascia that emanate from the medial aspect of the tuberosity but converge more distally and are thus found when doing the instep procedure.
Ed

Re: cure rates

Ed Davis, DPM on 6/21/02 at 19:16 (088254)

Joe:

Another reason for surgical failures is failure to address the contribution to pathology from a tight gastrosoleus achilles complex.
I, like others, find success with conservative treatment usually, but of the individuals who do go on to surgery, I perform an achilles lengthening or gastroc recession with about 40 to 50% of plantar fascial releases.
Ed

Re: cure rates

Joe S on 6/23/02 at 17:46 (088347)

I agree. I'm sure you as well as Dr. Z are aware of the amount of time it takes in order to get someone 'precertified'. The amount of time it takes my nurse to get the patient's record copied, put it in an envelope, and sent to Healthtronics takes about an hour. This puts her behind and she has to play catchup. An hour is alot of time. There are several other things she could be doing which would keep the flow of the office going. I've pretty much delegated friday afternoons to getting this (Ossatron Insurance/Medical Record) work done. I just can't afford her taking time away from patient care or other back office duties to do this.

Re: cure rates

john h on 6/24/02 at 09:28 (088364)

That cost is much more than reasonable Dr. Ed. Any guesses what the cost might be once this machine is approved in the U.S. market. What does this machine cost?