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Dr. z and others: questions about regular surgery....

Posted by cindy e. on 6/28/02 at 21:23 (088729)

After talking with you about my situation(1 failed ossatron),I have talked to the doc who did the procedure and he is willing to do another treatment for free other than the anesthesiologist bill($250). However, we also discussed the options of the small incision plantar facia release. He said his succcess rate was right at 99%. He said he has done hundreds and has extremely good results with people who didn't respond to the ossatron or has a bad case of plantar faciitis and several large spurs such as me. He said he smoothes down the main spur curving into the tendon and does the cut 2/3 of the way through. My podiatrist here in town gave me horrible stats as low as 50% cure and the other 30% somewhat improved and 20% major problems and failure as well as telling me he does the full open-heel cut and does'nt remove the spur. The doc who did my ossatron treatment said that if I had the time to be off and would follow post-op instructions that I should also have the 99% success rate. The follow up included 2 weeks in a cast ,then 4 weeks limited use. My insurance pays for everything with the regular surgery. I will still have to get a plane ticket either way(another $300).what is your opinion?!! thanks, cindy

Re: Dr. z and others: questions about regular surgery....

BrianJ on 6/28/02 at 21:54 (088733)

Personally, I would try all conventional treatments, as well as ESWT at least 3 times, before ever considering surgery. I would also get all the necessary work-ups to rule out other problems (Reiter's, arthritis, ankylosing spondylitis, heel fracture, etc.). Finally, I would try Neurontin to see if (if it decreases your pain)you may have a nerve-related issue. In my opinion after reading a great deal about PF surgery, a claim of 99% success for any type of PF surgery should be viewed with skepticism if 'success' implies (1)substantial pain relief and (2)no negative developments elsewhere in the foot.

Re: Dr. z and others: questions about regular surgery....

Dr. Zuckerman on 6/28/02 at 22:53 (088738)

Hi

I would do the second ESWT treatment if no relief and you have ruled out other causes then heel spur surgery would be the last step. Do the 2nd ESWT treatment. I have cured patients that have failed to get better with ESWT the first time around

Re: Dr. z and others: questions about regular surgery....

john h on 6/29/02 at 08:05 (088753)

Cindy: If the doc will do the 2nd Ossatron free and only $250 for the hospital then I would without doubt do that rather than have surgery. I have had surgery and I have had ESWT and in my mind there would be no question. You can always have surgery at a later date if needed. For $250 do not risk your feet!!!!!!!!!!!!!!!!!!!!!!!!!!!

Re: Dr. z and others: questions about regular surgery....

Ed Davis, DPM on 6/29/02 at 17:41 (088777)

Cindy:

It is definitely worth going a second round with the Ossatron. I am a bit uneasy with a claim of a '99%' success rate with the surgery.
Ed

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 10:13 (088923)

I am still at a loss as to why so many people are having he heel spur removed?

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/02/02 at 19:14 (088952)

John,

The answer is simple 'Money' A simple equation (Sore Feet = Big Money).
If you have a patient looking and begging for a cure from heelspur pain and the most common treatment you've been providing for years is surgery it's a no brainer. Why would you lose a patient to some other doctor without offering your cure first?

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/02/02 at 20:34 (088962)

The main reason that I see, is that most people are fixated on the spur no matter what they tell you. I NEVER remove the spur. Some people/patients who finally end up going the surgery route, insist on taking the spur. 1st of all, to get the proper reduction of the spur you need to perform the procedure under flouroscopy. It takes a little longer. Personally, I feel that there is too much dissection to get the spur as well as an increased chance of causing a stress fracture of the calcaneus (although remote). And the last reason I don't take the spur is because bone bleeds. When you smooth the 'heel spur' down, you're actually cutting bone. This increases your chance of postop wound complications. This is my opinion. I'm interested in what Dr.Z and Dr. Davis have to say. As an aside, I don't even discuss surgery with patients until all conservative efforts have failed.

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/02/02 at 20:48 (088964)

Pauline,

I would like to disagree with you. The reimbursement for heelspur resection or plantar fasciotomy (depending on where you live and what insurance company you have) varies. For instance, United Healthcare reimbursed me right around 400 dollars for a plantar fasciotomy. That includes all of the patients post op visits for 3 months as well as dressing changes (weekly) until the stitches come out in addition to any post op complication (infection, hematoma etc..). For the complications associated with 'heel spur surgery', the reimbursement is not worth it. I can count on one hand how many heel spur surgeries I've done in the last year and it is 4. That's it. I see inbetween 30 and 35 patients per day. Today I saw 8 heel pain patients. I typically see inbetween 4-6 patients a day with heel pain. You can do the math. I just got my 1st patient approved for ESWT after struggling with an Insurance company for 3 months. The guy actually wanted the open surgery due to his chronic pain. I have been seeing him for over a year now as well. We mainly communicate via email over the last 2 months (mainly for ESWT) and I don't bill him for our communication. I'm sure Dr. Z and Dr. Davis will also tell you that neither one of them do 'heel spur surgery' for money. It is not the cash cow or bread and butter of Podiatry that many people think. I'm not saying that there are not some unscrupulous doctors out there providing unecessary surgery (ie plantar fasciotomy with a TTS release). There are. I see their patients after they've been through the surgery without resolve. I truly wish Sore Feet = Big Money though. That's a good calling card for college kids who want to go into the medical field though....

Re: Dr. z and others: questions about regular surgery....

Dr. Zuckerman on 7/02/02 at 20:57 (088968)

This is why alot of insurance company won't cover ESWT when they can pay for heel spur surgery at the $400 rate. Now thereis some money to be made in the physical therapy route. The insurance companies pay alot of money for Physical Therapy, taping, injections, orthosis etc. It you figure that the average patient is seen for about two months that can be expensive.for the insurance companies.

How to pay for heel pain patient is a very difficult call. I have wondered that maybe it could be paid on a DRG scale. The doctor is paid a flat fee for every heel pain patient. There is going to be easy cases , moderate cases and hard cases. Each would have a different rates. They tried this for other diseases in New Jersey but they stopped so I stopped thinking about it

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/02/02 at 21:15 (088970)

I think recent articles put in print by some of your own colleagues will clarify where the cash cows are to be found in Podiatry. They agree with you. It's not all found in surgery, but in their words many surgical procedures are still being done by doctors who are not qualified to perform the surgery and they will not refer patients to other doctors. Is that for pride or greed?

You like many others in your field may be doing clean up for these unscrupulous doctors after the fact. If I recall the articles listed many other income producing treatments that could be substituted for surgery, yet they still choose to perform it.

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 21:27 (088974)

Joe: not removing the spur makes a lot of sense to me unless something else is going on. As we all know lots of people have spurs and no pain and lots of people have pain with no spurs.

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 21:35 (088975)

One of my local Podiatrist said he was reimbursed $375 for the surgery. He also said he does 300 or more a year. Think about this! We have a well known heart surgeon who several years ago did in excess of 1000 bypass surgeries in one year. He would go through several sets of nurses a day. He led the nation in numbers. From the Doctors and Nurses I have talked to they say is very quick and very precise and demanding. Also considered the best around these parts. I do not know what a bypass cost but it is well into the thousands.

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 21:38 (088978)

Unfortunately we have unscrupolous people in all professions. I think we just expect more from our Doctors, Priest, CEO's, Accountants,Presidents, and so on and son on----

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/02/02 at 21:51 (088984)

John,
I don't know of too many heart by-pass surgeries performed just to have income. I would venture to say that since most pre-surgical testing for by-pass surgery is conducted in the operating room with other witnesses a heart surgeon would be hard pressed to call for a by-pass on a healty patient if it wasn't warranted. Big life threatening differences between by-pass surgery and heel spur surgery.

Re: Dr. z and others: questions about regular surgery....

Sunny Jacob - Bayshore on 7/03/02 at 06:31 (089008)

'The human mind accepts a new idea about as graciously as the human body accepts a foreign protein.' (by Dr. Wilfred Trotter, Surgeon, University College London).
ESWT is still relatively new as a routine treatment in North America. Many surgeons and specialists have not even heard about ESWT. As with anything else, leaders will always be few. However, during the next ten years or so there will be many followers who will claim to be the leaders in ESWT.
Personally, I would choose surgery as the last resort. So far I could not find any scientific evidence in the literature about the high surgical success claims.

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/03/02 at 09:07 (089018)

Your right. Surgery should always be a last resort and a non-existent choice for those doctors who were never trained in the procedure they are suggesting to their patients.

After watching the surgical postings over several years I haven't been impresed with the results that have been posted. The pattern is easy to follow.

Re: Dr. z and others: questions about regular surgery....

Maggie L. on 7/03/02 at 14:17 (089043)

Cindy, Pauline just mentioned it, but just to clarify - there is another list on this website just like this list that is just for Foot Sugery. You probably already know this - but it took me a little while to notice it when I was first on this site so I'm just pointing it out!

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/03/02 at 20:34 (089069)

John,
I don't expect any more from people because they are Doctors, Priest, or CEO's. I expect them to be honest, forthright citizens like the majority of people. Equal to, but not above. Problem is many hold themselves as untouchable and above law. A profession by itself doesn't become greedy, it needs a greedy unscrupolous individual to make it that way.

Re: Dr. z and others: questions about regular surgery....

john h on 7/04/02 at 12:34 (089113)

Alas, Pauline man is flawed and in any group be they rich,poor,educated or uneducated there will be some bad apples. We often expect more of some professions than they are able to give. The profession does not make the man it is the other way around. Every since Adam took a bite of that apple things have headed south.

Re: Dr. z and others: questions about regular surgery....

john h on 7/05/02 at 07:46 (089159)

Pauline: The heart surgeon I am referrng to and I assmue most of them do not make the actual call on the surgery it is the Cardiologist who tells you that a bypass is needed. Since this doc is so proficient and has such a good track record he gets more referals than he can handle. He just like doing surgery and if he makes a lot of money along the way that seems to be the part of our econmic system. By the way I think he is on his 4th wife. You will need to do a lot surgery to support that lifestyle.

Re: Dr. z and others: questions about regular surgery....

john h on 7/05/02 at 07:47 (089160)

Sunny you will certainly not find a high success rate of surgery on this board.

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/05/02 at 11:46 (089172)

John,
I would venture to say that you'd be hard pressed to find more Cardiologist or Cardiac Surgeons calling for unwarranted bypass surgeries than Pods offering unwarranted surgical removals of Heel spurs no matter how many wives that had to support.

Re: Dr. z and others: questions about regular surgery....

john h on 7/05/02 at 14:41 (089181)

Touche! Pauline you are about 99.99% correct.

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/06/02 at 11:13 (089209)

I would honestly say that 95 percent of the physicians out there (podiatrists, MD's, DO's) etc.. do a real good job. And do the job for the right reason. It only takes a few of those guys too give us a bad name. Podiatry for the most part is a small profession. So when one guy really screws the system and gets caught, he or she messes it up for everyone. As far as doctors not referring cases out when they are truly not qualified to do them is very concerning to me. Personally, I don't think it's for greed or monetary purposes (well maybe a little) but I think these guys don't want to take a chance of losing their patient. I had a patient referred to me a couple of weeks ago by another local podiatrist who fractured their 1st metatarsal. He told me on the phone that he had never done one of these in the past. I saw the patient and called the referring pod back and told him that a surgical reduction (open reduction with internal fixation) was necessary and if he would like, he could scrub the case with me. I let him do most of the case with exception of the fixation and the patient is doing ok. I didn't steal the patient from him. I don't think he feels threatened either. I think that I bridged a little gap. I'm not going to preach that I'm a better surgeon than anyone in my town or talk anybody down. However, our main hospital that I'm on staff at just underwent a radical change in bylaws for our section. Our requirements to be on staff are fairly stringent. They are that you have had to complete at least a two year Surgical Residency and at least be Board Qualified and on the way to being Board Certified by the American Board of Podiatric Surgery. That is the only board Hospitals recognize. If you don't have these two requirements, then you can not even apply to the Hospital. I can tell you that I'm only one of four people that have the 'qualifications' to be on staff. The older guys who may not have had the opportunity to complete a 2 year plus surgical residency has been grandfathered in if they aer board certified. Anyway, just got back from vacation. Now back to work.

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/06/02 at 11:16 (089210)

Correct. That's why before making any decision be it ESWT or Surgery, the proper diagnosis needs to be made. If you are misdiagnosed, then no treatment will work.

Re: To Joe S

Joe S on 7/07/02 at 20:00 (089258)

I will shed some light on the residency situation. There are many excellent podiatrists who did not perform a residency believe it or not. These are the individuals typically in their late 40's and older. In the 'old days' residencies were few and far between. Most pods were taught by a preceptor. This was usually a very experienced indiviual who would bascially train podiatrists on certain surgical techniques. These individuals are now few and far between. I rarely hear of any podiatrists offer less trained pods for free. Now there are many excellent workshops out there which offer pods additional training in surgery. They actually have the pod perform procedures on cadavers before 'experimenting' on real patients. I've been to a few workshops (mainly external fixators) for fracture management. That's kind of part of my employment contract though. In the current climate residencies are in an abundance. There are certain procedures that I do not feel comfortable with an dI refer these out. Residency training is funny. Not all residencies see every single pathology. Every residency has their niche. For instance, their is one residency in San Antonio that is a 3 year surgical residency but it mainly specializes in care of the diabetic foot. That is what this residency is about. Don't go there thinking that you're gonna come out and be able to fix ankle fractures because you won't. You will be very well trained in Diabetic Limb Salvage though. The thing that gets me (I've been out of my residency 3 years) is that some of these older individuals will try the hardest to keep you off of insurance panels and out of some hospitals. When our current hospital bylaw situation came about, the one podiatrist who tried his hardest to keep me off of a certain insurance plan succeeded (initially) but when the rewrite of our staff bylaws came into effect he was shut out becuae he lacked a 2 year surgical residency and also is not board certified nor board qualified with the American Board of Podiatric Surgery. He is grandfathered in for 3 years but if he is not Board Certified or Qualified by then, he will be dismissed from the hospital staff. Seems like turnabout is fair play. This is the very podiatrist you are talking about. He does surgery behind closed doors weekly. I have seen numerous post op complications from his work as well. In our main office, we have a surgical suite as well. I perform minor procedures there but under TRUE STERILE TECHNIQUE. It is not only pods doing surgery in their offices either. Alot of Family Practitioners who perform minor surgery in their office under questionable sterility protocols. I had a patient come to me after having a ganglionic cyst excised from his ankle from his Family Practitioner in one of the treatment rooms. Just curiously questioning the patient, he told me that no mask was worn, just a 'sterile blue towel' was placed over his foot and the cyst was cutout. The guy luckily had an umcomplicated outcome. So it is not only pods doing this type of surgery.

As far the referring pod that didn't know how to do that certain procedure is not really uncommon. He actually did perform a surgical residency and is board certified by the american board of podiatric surgery. He is a good surgeon. He just does not see that much trauma. Most podiatrists don't see much trauma. I happen to have had quite a bit exposure to it in my residency. The procedure we did together is fairly easy. Most are just scared to attempt it for fear of bad outcome and then litigation.

I make it point to personally criticize anyone or any other physician. It's just not write. Plus it could be considered slander. Podiatrists think that we own the foot. We don't. There are many other individuals out there providing foot care than we think. I know very good podiatrists and I know very bad ones. The same holds true for orthopedists. One was just run out of town and is now in Nebraska or New Mexico.

Anyway, my posts are extremely longwinded so sorry about that.

Re: To Dr. Joe S

Pauline on 7/07/02 at 20:37 (089262)

I think this was a great honest summary. Nothing more needs to be said.

Re: To Joe S

Dr. Zuckerman on 7/08/02 at 09:45 (089282)

I am starting to feel old. I am in my late 40'S and our class of over 150
podiatrists recieved residency programs some two and a few three years of training. In the state of New Jersey all podiatrists need at least a one year surgical residency program to open a practice. So I guess the moral of the story, only get foot care in the state of New Jersey ( just joking.)

There is no doubt in my mind that the podiatrist is the one to see for heel pain. We treat the majority of heel pain and have the most training in the treatment of heel pain. Most foot and ankle orthopedic surgeons get about one year of foot and ankle training. This is a heel pain web site so I will only address heel pain.

Re: To Joe S

Joe S on 7/08/02 at 12:29 (089291)

You're right about the foot and ankle orthopods. I know of some who only get 6 months of a fellowship in foot and ankle. I don't understand this really. They could do so much better (financially) doing knee's, hips, and shoulders. I'm just wondering when the Family Practitioner's will get on board with ESWT and start doing them?

Re: Training in the care of "pain" itself ???

BrianG on 7/08/02 at 13:46 (089297)

Hi Dr. Z,

Since you mentioned heel pain, I'd like to know how much training the average Podiatris has had, in treating the 'pain' itself. My original Pod, with an HMO, refused to treat my pain with anything except anti-inflamatories and cortisone. When it became apparent they were not going to help me, he passed me off to a Neurologist, who wanted to try his anti seizure meds. None of these meds worked, either. Finally, after much persistance, I was able to get my family doctor to treat my pain with daily pain meds (narcotics). Why was everyone afraid to help me????? Can we expect better 'pain care' in the future?

Any other doctors, feel free to answer, thanks

BrianG

Re: Training in the care of "pain" itself ???

Dr. Zuckerman on 7/08/02 at 14:53 (089299)

The trainng is based how long much heel pain comes into your clinic.
Heel pain was covered in more then one subject. Podiatric medicine,
neurology, biomechanics. Biomechanics was the made focus at my school
We covered the surgical treatment of heel pain. When in clinic I saw alot of heel pain patients. I did three externships and the practices had alot of heel pain patients.

Podiatrists see alot of heel pain !!!!

Re: Training in the care of "pain" itself ???

Joe S on 7/08/02 at 20:53 (089325)

I see approximately 6-8 patients a day with heel pain. Probably pretty typical for a podiatrist. I believe that most physicians be them podiatrists, orthopods, and general practitioner's limit the amount of narcotics that they dispense. I know some are very liberal in dispensing however. There is such a drug craze out there right now with 'oxycontin' in the news almost daily that many are unwilling to write for pain meds. It is my policy to only prescribe pain meds (narcotics) for post op pain. I personally believe that if you are in that much chronic pain be it your foot, back or whatever, then you need to see a pain management specialist (typically an anesthesiologist who specializes in pain management). Personally I don't see a problem with sending a patient to a pain management guy for heel pain that has been nonresponsive to all treatment modalities. Also, getting back to why most pods don't write a lot of narcotics is that they don't want to create a profile as being a narcotic prescriber. Then everyone and their brother would be seeing you for 'pain meds'. It's a sad fact but a true one. Ask any of the other doctors on here. If they tell you different they're full of it.

Re: Pain, must be treated, just like any other symptom

BrianG on 7/08/02 at 21:31 (089328)

I believe what you say Joe, but I definetly think your in the minority when you say that you would refer someone to a pain clinic, if necessary. For years, I have been reading about patients with intractible pain. Maybe a hand full are referred to someone who can help them. Most patients have to beg, to get relief. I realize that no one wants to be known as the doctor who will prescribe pain meds to everyone who walks in the door. On the other hand, the patients need a break. When it's obvious that they can no longer function, due to chronic pain, they should all be referred to someone who can help them. At this time, it's not happening! I would hope in the future, that all doctors will treat pain, just as they would every other symptom, even if it requires a referrel. Patients have to be monitored, and checked, to ensure they are not abusing drugs. Everyone deserves a life, with minimal pain, the technology is certainly in place to accomplish this.

Regards
BrianG

Re: Pain, should still be treted

BrianG on 7/09/02 at 13:07 (089354)

I don't know where my original message went, but it seemed to get crossed up with some one elses. I used the old cut and paste, to find this copy. 2nd try :*)

Pain, must be treated, just like any other symptom View Thread
Posted by BrianG on 7/08/02 at 21:31
I believe what you say Joe, but I definetly think your in the minority when you say that you would refer someone to a pain clinic, if necessary. For years, I have been reading about patients with intractible pain. Maybe a hand full are referred to someone who can help them. Most patients have to beg, to get relief. I realize that no one wants to be known as the doctor who will prescribe pain meds to everyone who walks in the door. On the other hand, the patients need a break. When it's obvious that they can no longer function, due to chronic pain, they should all be referred to someone who can help them. At this time, it's not happening! I would hope in the future, that all doctors will treat pain, just as they would every other symptom, even if it requires a referrel. Patients have to be monitored, and checked, to ensure they are not abusing drugs. Everyone deserves a life, with minimal pain, the technology is certainly in place to accomplish this.

Regards
BrianG

Re: To Joe S

john h on 7/09/02 at 18:18 (089377)

PF may be one of those diseases that the patient plays as important a part in the healing as the Physician. Mabe more so.

Re: Pain, should still be treted

Joe S on 7/09/02 at 22:24 (089389)

You're exactly right. If you have chronic, intractable pain you should see a pain management specialist. That's their specialty. People with foot pain be it PF or whatever may not be their top priority but it should be treated. To be honest with you, I haven't had many patients actually plead with me to get pain meds. Even postoperatively. I've had a few but not many. I'm not ashamed to say if I can't help you then it's time for another opinion. I think that's where alot of patients get the run around. Their doctor keeps trying different things with no benefit and no recommendation to see someone else. Personally it's frustrating to me. I send patient's out for 2nd opinions fairly frequently when we're not getting anywhere with our current treatment protocol.

Re: Pain, should still be treted

john h on 7/10/02 at 18:14 (089433)

Joe: On tonights news they discussed a just completed medical study of orthroscopic knee surger. On one group of patients they made the holes in the knee for the scope but did no surgery on the knee. The others had the traditional orthroscopic surgery. Findings: patients who did not have the surgery felt as good as those that had the surgery and many say they no longer have pain. The placebo effect in action.

Re: Pain, should still be treted

Joe S on 7/10/02 at 18:27 (089435)

That's what you call a true clinical study. The same would hold true for ESWT as well. You could give some people the sham treatment and they would get better.

Re: Pain, should still be treted

john h on 7/11/02 at 11:18 (089472)

Joe: In the original clinical studies by the FDA on the Ossatron those showing improvement were really not that much higher than those that did not but apparently statistically significant enough to warrant it's approval. Certainly ESWT would be subject to the placebo effect much more so than say surgical procedures. Measuring the effects of ESWT is very subjective in that PF the disease is sort of a subjective disease.

Re: Pain, should still be treted

Sunny Jacob - Bayshore on 7/12/02 at 06:26 (089526)

There will be a lot of debates among medical ethicists about the surgical placebo study done at Baylor university (the recent study of an arthroscopic procedure for the knee). Such an invasive procedure, although it may be a placebo study, is prone to other complications such as post surgical infection.
There are several studies published about ESWT treatment and placebo effect. These, of course are non-invasive. Almost all of the studies showed that ESWT has a higher percentage of success than the placebo effect.

Re: To Joe S

pala on 9/26/02 at 19:51 (096279)

pauline, i agree with many of the things you say. but i had a less than positive experience at the mayo clinic. i would never go there again! and they were very very expensive. i think the whole medical establishment is damaged beyond repair and almost totally money driven now. there are exceptions of course, and i've come accross a few of them. but they are stellar in spite of this system. my gp is slowly being eliminated from all the preferred insurance providers because she actually cares about giving the best care she can. don't ask me how many lemons i had to sift through to find her. i don't write this to knock the docs here. they have helped me a lot, for free. that is stellar to me.

Re: To Joe S

pala on 11/14/02 at 15:28 (100162)

for the record i had a really lousy experience at the mayo clinic and it was very expensive. i'm still paying off the bill years later. i think all medical places and practioners can be criticized. actually in my experience most should be. often. although i've found a few good ones mostly it's been horrible. i think, on the whole the orth md is not better or worse a person, a practitioner a moral guy than the pod, the pt, the orthotist, the faith healer, the medicine man. how to find the good ones without going through scores of bad ones, i just don't know. as far as i can tell the whole medical system is broken in this country. a disasterous equation: pain + vulnerability + medical profession + money = the mess i and many others are in

Re: To Joe S

pala on 11/14/02 at 15:30 (100163)

p.s. the pods here on this board have helped me more than the legions of md 's and pods i threw so much money away on.

Re: Dr. z and others: questions about regular surgery....

BrianJ on 6/28/02 at 21:54 (088733)

Personally, I would try all conventional treatments, as well as ESWT at least 3 times, before ever considering surgery. I would also get all the necessary work-ups to rule out other problems (Reiter's, arthritis, ankylosing spondylitis, heel fracture, etc.). Finally, I would try Neurontin to see if (if it decreases your pain)you may have a nerve-related issue. In my opinion after reading a great deal about PF surgery, a claim of 99% success for any type of PF surgery should be viewed with skepticism if 'success' implies (1)substantial pain relief and (2)no negative developments elsewhere in the foot.

Re: Dr. z and others: questions about regular surgery....

Dr. Zuckerman on 6/28/02 at 22:53 (088738)

Hi

I would do the second ESWT treatment if no relief and you have ruled out other causes then heel spur surgery would be the last step. Do the 2nd ESWT treatment. I have cured patients that have failed to get better with ESWT the first time around

Re: Dr. z and others: questions about regular surgery....

john h on 6/29/02 at 08:05 (088753)

Cindy: If the doc will do the 2nd Ossatron free and only $250 for the hospital then I would without doubt do that rather than have surgery. I have had surgery and I have had ESWT and in my mind there would be no question. You can always have surgery at a later date if needed. For $250 do not risk your feet!!!!!!!!!!!!!!!!!!!!!!!!!!!

Re: Dr. z and others: questions about regular surgery....

Ed Davis, DPM on 6/29/02 at 17:41 (088777)

Cindy:

It is definitely worth going a second round with the Ossatron. I am a bit uneasy with a claim of a '99%' success rate with the surgery.
Ed

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 10:13 (088923)

I am still at a loss as to why so many people are having he heel spur removed?

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/02/02 at 19:14 (088952)

John,

The answer is simple 'Money' A simple equation (Sore Feet = Big Money).
If you have a patient looking and begging for a cure from heelspur pain and the most common treatment you've been providing for years is surgery it's a no brainer. Why would you lose a patient to some other doctor without offering your cure first?

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/02/02 at 20:34 (088962)

The main reason that I see, is that most people are fixated on the spur no matter what they tell you. I NEVER remove the spur. Some people/patients who finally end up going the surgery route, insist on taking the spur. 1st of all, to get the proper reduction of the spur you need to perform the procedure under flouroscopy. It takes a little longer. Personally, I feel that there is too much dissection to get the spur as well as an increased chance of causing a stress fracture of the calcaneus (although remote). And the last reason I don't take the spur is because bone bleeds. When you smooth the 'heel spur' down, you're actually cutting bone. This increases your chance of postop wound complications. This is my opinion. I'm interested in what Dr.Z and Dr. Davis have to say. As an aside, I don't even discuss surgery with patients until all conservative efforts have failed.

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/02/02 at 20:48 (088964)

Pauline,

I would like to disagree with you. The reimbursement for heelspur resection or plantar fasciotomy (depending on where you live and what insurance company you have) varies. For instance, United Healthcare reimbursed me right around 400 dollars for a plantar fasciotomy. That includes all of the patients post op visits for 3 months as well as dressing changes (weekly) until the stitches come out in addition to any post op complication (infection, hematoma etc..). For the complications associated with 'heel spur surgery', the reimbursement is not worth it. I can count on one hand how many heel spur surgeries I've done in the last year and it is 4. That's it. I see inbetween 30 and 35 patients per day. Today I saw 8 heel pain patients. I typically see inbetween 4-6 patients a day with heel pain. You can do the math. I just got my 1st patient approved for ESWT after struggling with an Insurance company for 3 months. The guy actually wanted the open surgery due to his chronic pain. I have been seeing him for over a year now as well. We mainly communicate via email over the last 2 months (mainly for ESWT) and I don't bill him for our communication. I'm sure Dr. Z and Dr. Davis will also tell you that neither one of them do 'heel spur surgery' for money. It is not the cash cow or bread and butter of Podiatry that many people think. I'm not saying that there are not some unscrupulous doctors out there providing unecessary surgery (ie plantar fasciotomy with a TTS release). There are. I see their patients after they've been through the surgery without resolve. I truly wish Sore Feet = Big Money though. That's a good calling card for college kids who want to go into the medical field though....

Re: Dr. z and others: questions about regular surgery....

Dr. Zuckerman on 7/02/02 at 20:57 (088968)

This is why alot of insurance company won't cover ESWT when they can pay for heel spur surgery at the $400 rate. Now thereis some money to be made in the physical therapy route. The insurance companies pay alot of money for Physical Therapy, taping, injections, orthosis etc. It you figure that the average patient is seen for about two months that can be expensive.for the insurance companies.

How to pay for heel pain patient is a very difficult call. I have wondered that maybe it could be paid on a DRG scale. The doctor is paid a flat fee for every heel pain patient. There is going to be easy cases , moderate cases and hard cases. Each would have a different rates. They tried this for other diseases in New Jersey but they stopped so I stopped thinking about it

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/02/02 at 21:15 (088970)

I think recent articles put in print by some of your own colleagues will clarify where the cash cows are to be found in Podiatry. They agree with you. It's not all found in surgery, but in their words many surgical procedures are still being done by doctors who are not qualified to perform the surgery and they will not refer patients to other doctors. Is that for pride or greed?

You like many others in your field may be doing clean up for these unscrupulous doctors after the fact. If I recall the articles listed many other income producing treatments that could be substituted for surgery, yet they still choose to perform it.

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 21:27 (088974)

Joe: not removing the spur makes a lot of sense to me unless something else is going on. As we all know lots of people have spurs and no pain and lots of people have pain with no spurs.

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 21:35 (088975)

One of my local Podiatrist said he was reimbursed $375 for the surgery. He also said he does 300 or more a year. Think about this! We have a well known heart surgeon who several years ago did in excess of 1000 bypass surgeries in one year. He would go through several sets of nurses a day. He led the nation in numbers. From the Doctors and Nurses I have talked to they say is very quick and very precise and demanding. Also considered the best around these parts. I do not know what a bypass cost but it is well into the thousands.

Re: Dr. z and others: questions about regular surgery....

john h on 7/02/02 at 21:38 (088978)

Unfortunately we have unscrupolous people in all professions. I think we just expect more from our Doctors, Priest, CEO's, Accountants,Presidents, and so on and son on----

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/02/02 at 21:51 (088984)

John,
I don't know of too many heart by-pass surgeries performed just to have income. I would venture to say that since most pre-surgical testing for by-pass surgery is conducted in the operating room with other witnesses a heart surgeon would be hard pressed to call for a by-pass on a healty patient if it wasn't warranted. Big life threatening differences between by-pass surgery and heel spur surgery.

Re: Dr. z and others: questions about regular surgery....

Sunny Jacob - Bayshore on 7/03/02 at 06:31 (089008)

'The human mind accepts a new idea about as graciously as the human body accepts a foreign protein.' (by Dr. Wilfred Trotter, Surgeon, University College London).
ESWT is still relatively new as a routine treatment in North America. Many surgeons and specialists have not even heard about ESWT. As with anything else, leaders will always be few. However, during the next ten years or so there will be many followers who will claim to be the leaders in ESWT.
Personally, I would choose surgery as the last resort. So far I could not find any scientific evidence in the literature about the high surgical success claims.

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/03/02 at 09:07 (089018)

Your right. Surgery should always be a last resort and a non-existent choice for those doctors who were never trained in the procedure they are suggesting to their patients.

After watching the surgical postings over several years I haven't been impresed with the results that have been posted. The pattern is easy to follow.

Re: Dr. z and others: questions about regular surgery....

Maggie L. on 7/03/02 at 14:17 (089043)

Cindy, Pauline just mentioned it, but just to clarify - there is another list on this website just like this list that is just for Foot Sugery. You probably already know this - but it took me a little while to notice it when I was first on this site so I'm just pointing it out!

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/03/02 at 20:34 (089069)

John,
I don't expect any more from people because they are Doctors, Priest, or CEO's. I expect them to be honest, forthright citizens like the majority of people. Equal to, but not above. Problem is many hold themselves as untouchable and above law. A profession by itself doesn't become greedy, it needs a greedy unscrupolous individual to make it that way.

Re: Dr. z and others: questions about regular surgery....

john h on 7/04/02 at 12:34 (089113)

Alas, Pauline man is flawed and in any group be they rich,poor,educated or uneducated there will be some bad apples. We often expect more of some professions than they are able to give. The profession does not make the man it is the other way around. Every since Adam took a bite of that apple things have headed south.

Re: Dr. z and others: questions about regular surgery....

john h on 7/05/02 at 07:46 (089159)

Pauline: The heart surgeon I am referrng to and I assmue most of them do not make the actual call on the surgery it is the Cardiologist who tells you that a bypass is needed. Since this doc is so proficient and has such a good track record he gets more referals than he can handle. He just like doing surgery and if he makes a lot of money along the way that seems to be the part of our econmic system. By the way I think he is on his 4th wife. You will need to do a lot surgery to support that lifestyle.

Re: Dr. z and others: questions about regular surgery....

john h on 7/05/02 at 07:47 (089160)

Sunny you will certainly not find a high success rate of surgery on this board.

Re: Dr. z and others: questions about regular surgery....

Pauline on 7/05/02 at 11:46 (089172)

John,
I would venture to say that you'd be hard pressed to find more Cardiologist or Cardiac Surgeons calling for unwarranted bypass surgeries than Pods offering unwarranted surgical removals of Heel spurs no matter how many wives that had to support.

Re: Dr. z and others: questions about regular surgery....

john h on 7/05/02 at 14:41 (089181)

Touche! Pauline you are about 99.99% correct.

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/06/02 at 11:13 (089209)

I would honestly say that 95 percent of the physicians out there (podiatrists, MD's, DO's) etc.. do a real good job. And do the job for the right reason. It only takes a few of those guys too give us a bad name. Podiatry for the most part is a small profession. So when one guy really screws the system and gets caught, he or she messes it up for everyone. As far as doctors not referring cases out when they are truly not qualified to do them is very concerning to me. Personally, I don't think it's for greed or monetary purposes (well maybe a little) but I think these guys don't want to take a chance of losing their patient. I had a patient referred to me a couple of weeks ago by another local podiatrist who fractured their 1st metatarsal. He told me on the phone that he had never done one of these in the past. I saw the patient and called the referring pod back and told him that a surgical reduction (open reduction with internal fixation) was necessary and if he would like, he could scrub the case with me. I let him do most of the case with exception of the fixation and the patient is doing ok. I didn't steal the patient from him. I don't think he feels threatened either. I think that I bridged a little gap. I'm not going to preach that I'm a better surgeon than anyone in my town or talk anybody down. However, our main hospital that I'm on staff at just underwent a radical change in bylaws for our section. Our requirements to be on staff are fairly stringent. They are that you have had to complete at least a two year Surgical Residency and at least be Board Qualified and on the way to being Board Certified by the American Board of Podiatric Surgery. That is the only board Hospitals recognize. If you don't have these two requirements, then you can not even apply to the Hospital. I can tell you that I'm only one of four people that have the 'qualifications' to be on staff. The older guys who may not have had the opportunity to complete a 2 year plus surgical residency has been grandfathered in if they aer board certified. Anyway, just got back from vacation. Now back to work.

Re: Dr. z and others: questions about regular surgery....

Joe S on 7/06/02 at 11:16 (089210)

Correct. That's why before making any decision be it ESWT or Surgery, the proper diagnosis needs to be made. If you are misdiagnosed, then no treatment will work.

Re: To Joe S

Joe S on 7/07/02 at 20:00 (089258)

I will shed some light on the residency situation. There are many excellent podiatrists who did not perform a residency believe it or not. These are the individuals typically in their late 40's and older. In the 'old days' residencies were few and far between. Most pods were taught by a preceptor. This was usually a very experienced indiviual who would bascially train podiatrists on certain surgical techniques. These individuals are now few and far between. I rarely hear of any podiatrists offer less trained pods for free. Now there are many excellent workshops out there which offer pods additional training in surgery. They actually have the pod perform procedures on cadavers before 'experimenting' on real patients. I've been to a few workshops (mainly external fixators) for fracture management. That's kind of part of my employment contract though. In the current climate residencies are in an abundance. There are certain procedures that I do not feel comfortable with an dI refer these out. Residency training is funny. Not all residencies see every single pathology. Every residency has their niche. For instance, their is one residency in San Antonio that is a 3 year surgical residency but it mainly specializes in care of the diabetic foot. That is what this residency is about. Don't go there thinking that you're gonna come out and be able to fix ankle fractures because you won't. You will be very well trained in Diabetic Limb Salvage though. The thing that gets me (I've been out of my residency 3 years) is that some of these older individuals will try the hardest to keep you off of insurance panels and out of some hospitals. When our current hospital bylaw situation came about, the one podiatrist who tried his hardest to keep me off of a certain insurance plan succeeded (initially) but when the rewrite of our staff bylaws came into effect he was shut out becuae he lacked a 2 year surgical residency and also is not board certified nor board qualified with the American Board of Podiatric Surgery. He is grandfathered in for 3 years but if he is not Board Certified or Qualified by then, he will be dismissed from the hospital staff. Seems like turnabout is fair play. This is the very podiatrist you are talking about. He does surgery behind closed doors weekly. I have seen numerous post op complications from his work as well. In our main office, we have a surgical suite as well. I perform minor procedures there but under TRUE STERILE TECHNIQUE. It is not only pods doing surgery in their offices either. Alot of Family Practitioners who perform minor surgery in their office under questionable sterility protocols. I had a patient come to me after having a ganglionic cyst excised from his ankle from his Family Practitioner in one of the treatment rooms. Just curiously questioning the patient, he told me that no mask was worn, just a 'sterile blue towel' was placed over his foot and the cyst was cutout. The guy luckily had an umcomplicated outcome. So it is not only pods doing this type of surgery.

As far the referring pod that didn't know how to do that certain procedure is not really uncommon. He actually did perform a surgical residency and is board certified by the american board of podiatric surgery. He is a good surgeon. He just does not see that much trauma. Most podiatrists don't see much trauma. I happen to have had quite a bit exposure to it in my residency. The procedure we did together is fairly easy. Most are just scared to attempt it for fear of bad outcome and then litigation.

I make it point to personally criticize anyone or any other physician. It's just not write. Plus it could be considered slander. Podiatrists think that we own the foot. We don't. There are many other individuals out there providing foot care than we think. I know very good podiatrists and I know very bad ones. The same holds true for orthopedists. One was just run out of town and is now in Nebraska or New Mexico.

Anyway, my posts are extremely longwinded so sorry about that.

Re: To Dr. Joe S

Pauline on 7/07/02 at 20:37 (089262)

I think this was a great honest summary. Nothing more needs to be said.

Re: To Joe S

Dr. Zuckerman on 7/08/02 at 09:45 (089282)

I am starting to feel old. I am in my late 40'S and our class of over 150
podiatrists recieved residency programs some two and a few three years of training. In the state of New Jersey all podiatrists need at least a one year surgical residency program to open a practice. So I guess the moral of the story, only get foot care in the state of New Jersey ( just joking.)

There is no doubt in my mind that the podiatrist is the one to see for heel pain. We treat the majority of heel pain and have the most training in the treatment of heel pain. Most foot and ankle orthopedic surgeons get about one year of foot and ankle training. This is a heel pain web site so I will only address heel pain.

Re: To Joe S

Joe S on 7/08/02 at 12:29 (089291)

You're right about the foot and ankle orthopods. I know of some who only get 6 months of a fellowship in foot and ankle. I don't understand this really. They could do so much better (financially) doing knee's, hips, and shoulders. I'm just wondering when the Family Practitioner's will get on board with ESWT and start doing them?

Re: Training in the care of "pain" itself ???

BrianG on 7/08/02 at 13:46 (089297)

Hi Dr. Z,

Since you mentioned heel pain, I'd like to know how much training the average Podiatris has had, in treating the 'pain' itself. My original Pod, with an HMO, refused to treat my pain with anything except anti-inflamatories and cortisone. When it became apparent they were not going to help me, he passed me off to a Neurologist, who wanted to try his anti seizure meds. None of these meds worked, either. Finally, after much persistance, I was able to get my family doctor to treat my pain with daily pain meds (narcotics). Why was everyone afraid to help me????? Can we expect better 'pain care' in the future?

Any other doctors, feel free to answer, thanks

BrianG

Re: Training in the care of "pain" itself ???

Dr. Zuckerman on 7/08/02 at 14:53 (089299)

The trainng is based how long much heel pain comes into your clinic.
Heel pain was covered in more then one subject. Podiatric medicine,
neurology, biomechanics. Biomechanics was the made focus at my school
We covered the surgical treatment of heel pain. When in clinic I saw alot of heel pain patients. I did three externships and the practices had alot of heel pain patients.

Podiatrists see alot of heel pain !!!!

Re: Training in the care of "pain" itself ???

Joe S on 7/08/02 at 20:53 (089325)

I see approximately 6-8 patients a day with heel pain. Probably pretty typical for a podiatrist. I believe that most physicians be them podiatrists, orthopods, and general practitioner's limit the amount of narcotics that they dispense. I know some are very liberal in dispensing however. There is such a drug craze out there right now with 'oxycontin' in the news almost daily that many are unwilling to write for pain meds. It is my policy to only prescribe pain meds (narcotics) for post op pain. I personally believe that if you are in that much chronic pain be it your foot, back or whatever, then you need to see a pain management specialist (typically an anesthesiologist who specializes in pain management). Personally I don't see a problem with sending a patient to a pain management guy for heel pain that has been nonresponsive to all treatment modalities. Also, getting back to why most pods don't write a lot of narcotics is that they don't want to create a profile as being a narcotic prescriber. Then everyone and their brother would be seeing you for 'pain meds'. It's a sad fact but a true one. Ask any of the other doctors on here. If they tell you different they're full of it.

Re: Pain, must be treated, just like any other symptom

BrianG on 7/08/02 at 21:31 (089328)

I believe what you say Joe, but I definetly think your in the minority when you say that you would refer someone to a pain clinic, if necessary. For years, I have been reading about patients with intractible pain. Maybe a hand full are referred to someone who can help them. Most patients have to beg, to get relief. I realize that no one wants to be known as the doctor who will prescribe pain meds to everyone who walks in the door. On the other hand, the patients need a break. When it's obvious that they can no longer function, due to chronic pain, they should all be referred to someone who can help them. At this time, it's not happening! I would hope in the future, that all doctors will treat pain, just as they would every other symptom, even if it requires a referrel. Patients have to be monitored, and checked, to ensure they are not abusing drugs. Everyone deserves a life, with minimal pain, the technology is certainly in place to accomplish this.

Regards
BrianG

Re: Pain, should still be treted

BrianG on 7/09/02 at 13:07 (089354)

I don't know where my original message went, but it seemed to get crossed up with some one elses. I used the old cut and paste, to find this copy. 2nd try :*)

Pain, must be treated, just like any other symptom View Thread
Posted by BrianG on 7/08/02 at 21:31
I believe what you say Joe, but I definetly think your in the minority when you say that you would refer someone to a pain clinic, if necessary. For years, I have been reading about patients with intractible pain. Maybe a hand full are referred to someone who can help them. Most patients have to beg, to get relief. I realize that no one wants to be known as the doctor who will prescribe pain meds to everyone who walks in the door. On the other hand, the patients need a break. When it's obvious that they can no longer function, due to chronic pain, they should all be referred to someone who can help them. At this time, it's not happening! I would hope in the future, that all doctors will treat pain, just as they would every other symptom, even if it requires a referrel. Patients have to be monitored, and checked, to ensure they are not abusing drugs. Everyone deserves a life, with minimal pain, the technology is certainly in place to accomplish this.

Regards
BrianG

Re: To Joe S

john h on 7/09/02 at 18:18 (089377)

PF may be one of those diseases that the patient plays as important a part in the healing as the Physician. Mabe more so.

Re: Pain, should still be treted

Joe S on 7/09/02 at 22:24 (089389)

You're exactly right. If you have chronic, intractable pain you should see a pain management specialist. That's their specialty. People with foot pain be it PF or whatever may not be their top priority but it should be treated. To be honest with you, I haven't had many patients actually plead with me to get pain meds. Even postoperatively. I've had a few but not many. I'm not ashamed to say if I can't help you then it's time for another opinion. I think that's where alot of patients get the run around. Their doctor keeps trying different things with no benefit and no recommendation to see someone else. Personally it's frustrating to me. I send patient's out for 2nd opinions fairly frequently when we're not getting anywhere with our current treatment protocol.

Re: Pain, should still be treted

john h on 7/10/02 at 18:14 (089433)

Joe: On tonights news they discussed a just completed medical study of orthroscopic knee surger. On one group of patients they made the holes in the knee for the scope but did no surgery on the knee. The others had the traditional orthroscopic surgery. Findings: patients who did not have the surgery felt as good as those that had the surgery and many say they no longer have pain. The placebo effect in action.

Re: Pain, should still be treted

Joe S on 7/10/02 at 18:27 (089435)

That's what you call a true clinical study. The same would hold true for ESWT as well. You could give some people the sham treatment and they would get better.

Re: Pain, should still be treted

john h on 7/11/02 at 11:18 (089472)

Joe: In the original clinical studies by the FDA on the Ossatron those showing improvement were really not that much higher than those that did not but apparently statistically significant enough to warrant it's approval. Certainly ESWT would be subject to the placebo effect much more so than say surgical procedures. Measuring the effects of ESWT is very subjective in that PF the disease is sort of a subjective disease.

Re: Pain, should still be treted

Sunny Jacob - Bayshore on 7/12/02 at 06:26 (089526)

There will be a lot of debates among medical ethicists about the surgical placebo study done at Baylor university (the recent study of an arthroscopic procedure for the knee). Such an invasive procedure, although it may be a placebo study, is prone to other complications such as post surgical infection.
There are several studies published about ESWT treatment and placebo effect. These, of course are non-invasive. Almost all of the studies showed that ESWT has a higher percentage of success than the placebo effect.

Re: To Joe S

pala on 9/26/02 at 19:51 (096279)

pauline, i agree with many of the things you say. but i had a less than positive experience at the mayo clinic. i would never go there again! and they were very very expensive. i think the whole medical establishment is damaged beyond repair and almost totally money driven now. there are exceptions of course, and i've come accross a few of them. but they are stellar in spite of this system. my gp is slowly being eliminated from all the preferred insurance providers because she actually cares about giving the best care she can. don't ask me how many lemons i had to sift through to find her. i don't write this to knock the docs here. they have helped me a lot, for free. that is stellar to me.

Re: To Joe S

pala on 11/14/02 at 15:28 (100162)

for the record i had a really lousy experience at the mayo clinic and it was very expensive. i'm still paying off the bill years later. i think all medical places and practioners can be criticized. actually in my experience most should be. often. although i've found a few good ones mostly it's been horrible. i think, on the whole the orth md is not better or worse a person, a practitioner a moral guy than the pod, the pt, the orthotist, the faith healer, the medicine man. how to find the good ones without going through scores of bad ones, i just don't know. as far as i can tell the whole medical system is broken in this country. a disasterous equation: pain + vulnerability + medical profession + money = the mess i and many others are in

Re: To Joe S

pala on 11/14/02 at 15:30 (100163)

p.s. the pods here on this board have helped me more than the legions of md 's and pods i threw so much money away on.