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is there a relationship between failed ESWT and surgical success rates?

Posted by elliott on 7/28/02 at 13:02 (090805)

That is, are the chances for surgical success (however defined) lower for someone who has failed to respond to ESWT?

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Re: is there a relationship between failed ESWT and surgical success rates?

Dr. Zuckerman on 7/28/02 at 20:55 (090862)

The literature states that the is no increase risk of failure if ESWT fails . I have a few patients that have been cured after failed ESWT. I also have cured patients that have failed heel spur surgery and then ESWT

Re: OK, then, so who is cooking the books?

elliott on 7/29/02 at 09:06 (090891)

PF is treated through 1)traditional conservative means, 2)ESWT, and 3) surgery. Define 'cure' below to mean producing satisfactory results.

The generally accepted probability of curing PF by conservative means is 90%. Here's one source repeating that oft-quoted figure:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797213&dopt=Abstract

For ESWT, while there has been a stated cure range of around 62-90%, it seems like the probability is currently zoning in on around 82%, and the probability of being cured through surgery is generally accepted to be around 83% (some say even higher). Here's these two figures:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12075904&dopt=Abstract

Well, since conservative means are typically (and should be) tried first, we can consider the first independent of the next two, and (thanks, Dr. Z!) it's also true that the second and third are independent of each other as well. Conveniently a collection of more or less independent events. Then, assuming one tries all available means to be rid of PF and does so in the suggested and common-sense order given above (conservative, ESWT, surgery), the probability of being cured is

.9 + (.1)(.82) + (.1)(.18)(.83) = .99694, or 99.7%. Chances of a cure by nonsurgical means should be the sum of the first two expressions, or 98.2%. Given traditional conservative means failed for someone, the probability of being cured is still .82 + (.18)(.83) = 96.9%. So PF should have gone more or less the way of smallpox, with only a few rare intransigent cases. Then what's everyone doing here?

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Re: OK, then, so who is cooking the books?

Ed Davis, DPM on 7/29/02 at 12:42 (090904)

Need to look at criteria used for defining 'intractable' plantar fasciitis.
See posts concerning Dr. Lee's success rates. Success rates for ESWT will be higher when 'all' variables are dealt with, ie. biomechanics have been adequately addressed going into procedure.
Ed

Re: OK, then, so who is cooking the books?

Dr. Zuckerman on 7/29/02 at 15:29 (090917)

Maybe we aren't always dealing with Pf. Some patients on this board have chronic pain with pf . So maybe its pf with other conditions

Re: OK, then, so who is cooking the books?

john h on 7/29/02 at 17:44 (090930)

Dr. Z: I have not idea what the percentage might be but I strongly suspect that many of our board members pain could be from something other than PF. PF is somewhat of a mystery anyway. Just look at our post, symptoms,cures,etc.

Re: but that's precisely part of the risk

elliott on 7/29/02 at 22:46 (090956)

Someone has something resembling PF. There may or may not be accompanying or contributing conditions. The foot is intractable with conservative methods. A decision as to surgery is made.

You could replace 'PF' in the above paragraph with 'TTS' and it still reads. What you're saying is no doubt true, yet since it is not always easy to separate things out, that would be considered part and parcel of the surgery and the associated success rates. In fact, I'd go as far as to say that mistaken diagnoses and hence the wrong surgery *should* be included in the stats.

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Re: but that's precisely part of the risk

john h on 7/30/02 at 09:12 (090977)

The orthopedic foot and ankle surgeon who did my left foot said you can never be sure about TTS even with the various test and that if I wanted to do a TTS surgery at the same time as my PF it would only last about 20 minutes longer. He said it was my call. As I rolled into surgery I gave him the go ahead on the TTS. Glad I did because I eliminated that as a possibilty.The TTS surgery and PF (Baxter Procedure) really caused me little pain and I was up and in shoes in 2 weeks. He will no perform any surgery on the fascia unless you have been treated conservatively for one year or more.

Re: but that's precisely part of the risk

Joe S on 7/31/02 at 00:14 (091073)

Elliot,

I think we finally agree on this one point. Actually I think we never truly disagreed. But anyway, here is my take and this is what I see in my practice. I would say roughly 90 percent of my patient population respond to conservative care. If patients are not responding then you need to be looking at other conditions which may affect the heel. I had a lady today who is not responding whatsoever. No history of trauma or anything. No symptoms in the tarsal tunnel. So I sending her for a bone scan to rule out a stress fracture of the calcaneus. I think one thing alot of docs be it a pod or an orthopedist typically do when they see heel pain is say it is PF. How many people get misdiagnosed with PF? I don't know. I bet it is alot. The same holds true with TTS as well. I think that when a lot of people see someone come in with pain is that general region and is not responsive to the tried and true conservative modialities that work, they just tell the patients 'Ms. Jones....You got PF or TTS' and leave it at that. That's not being a diagnostician. That's just someone throwing their hands up in the air. I like to get it right. I don't every time. But I like to try. It's kind of a game. I would say and probably the other docs on here will tell you this as well that most patients can and will ultimately tell you what they have just through their clinical symptoms.

Re: Well, I may disagree on one thing

elliott on 7/31/02 at 10:43 (091139)

No matter; sticks and stones may break my bones...

:-)

Re: Well, I may disagree on one thing

Joe S on 7/31/02 at 12:51 (091148)

literally

Re: Joe S & Elliot

Pete R on 7/31/02 at 13:58 (091161)

Are you both pods / doctors etc ?

Re: Joe S & Elliot

elliott on 7/31/02 at 14:50 (091168)

He's a pod, I'm a nothing layman TTS/heelpain sufferer.

---

Re: is there a relationship between failed ESWT and surgical success rates?

Dr. Zuckerman on 7/28/02 at 20:55 (090862)

The literature states that the is no increase risk of failure if ESWT fails . I have a few patients that have been cured after failed ESWT. I also have cured patients that have failed heel spur surgery and then ESWT

Re: OK, then, so who is cooking the books?

elliott on 7/29/02 at 09:06 (090891)

PF is treated through 1)traditional conservative means, 2)ESWT, and 3) surgery. Define 'cure' below to mean producing satisfactory results.

The generally accepted probability of curing PF by conservative means is 90%. Here's one source repeating that oft-quoted figure:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797213&dopt=Abstract

For ESWT, while there has been a stated cure range of around 62-90%, it seems like the probability is currently zoning in on around 82%, and the probability of being cured through surgery is generally accepted to be around 83% (some say even higher). Here's these two figures:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12075904&dopt=Abstract

Well, since conservative means are typically (and should be) tried first, we can consider the first independent of the next two, and (thanks, Dr. Z!) it's also true that the second and third are independent of each other as well. Conveniently a collection of more or less independent events. Then, assuming one tries all available means to be rid of PF and does so in the suggested and common-sense order given above (conservative, ESWT, surgery), the probability of being cured is

.9 + (.1)(.82) + (.1)(.18)(.83) = .99694, or 99.7%. Chances of a cure by nonsurgical means should be the sum of the first two expressions, or 98.2%. Given traditional conservative means failed for someone, the probability of being cured is still .82 + (.18)(.83) = 96.9%. So PF should have gone more or less the way of smallpox, with only a few rare intransigent cases. Then what's everyone doing here?

---

Re: OK, then, so who is cooking the books?

Ed Davis, DPM on 7/29/02 at 12:42 (090904)

Need to look at criteria used for defining 'intractable' plantar fasciitis.
See posts concerning Dr. Lee's success rates. Success rates for ESWT will be higher when 'all' variables are dealt with, ie. biomechanics have been adequately addressed going into procedure.
Ed

Re: OK, then, so who is cooking the books?

Dr. Zuckerman on 7/29/02 at 15:29 (090917)

Maybe we aren't always dealing with Pf. Some patients on this board have chronic pain with pf . So maybe its pf with other conditions

Re: OK, then, so who is cooking the books?

john h on 7/29/02 at 17:44 (090930)

Dr. Z: I have not idea what the percentage might be but I strongly suspect that many of our board members pain could be from something other than PF. PF is somewhat of a mystery anyway. Just look at our post, symptoms,cures,etc.

Re: but that's precisely part of the risk

elliott on 7/29/02 at 22:46 (090956)

Someone has something resembling PF. There may or may not be accompanying or contributing conditions. The foot is intractable with conservative methods. A decision as to surgery is made.

You could replace 'PF' in the above paragraph with 'TTS' and it still reads. What you're saying is no doubt true, yet since it is not always easy to separate things out, that would be considered part and parcel of the surgery and the associated success rates. In fact, I'd go as far as to say that mistaken diagnoses and hence the wrong surgery *should* be included in the stats.

---

Re: but that's precisely part of the risk

john h on 7/30/02 at 09:12 (090977)

The orthopedic foot and ankle surgeon who did my left foot said you can never be sure about TTS even with the various test and that if I wanted to do a TTS surgery at the same time as my PF it would only last about 20 minutes longer. He said it was my call. As I rolled into surgery I gave him the go ahead on the TTS. Glad I did because I eliminated that as a possibilty.The TTS surgery and PF (Baxter Procedure) really caused me little pain and I was up and in shoes in 2 weeks. He will no perform any surgery on the fascia unless you have been treated conservatively for one year or more.

Re: but that's precisely part of the risk

Joe S on 7/31/02 at 00:14 (091073)

Elliot,

I think we finally agree on this one point. Actually I think we never truly disagreed. But anyway, here is my take and this is what I see in my practice. I would say roughly 90 percent of my patient population respond to conservative care. If patients are not responding then you need to be looking at other conditions which may affect the heel. I had a lady today who is not responding whatsoever. No history of trauma or anything. No symptoms in the tarsal tunnel. So I sending her for a bone scan to rule out a stress fracture of the calcaneus. I think one thing alot of docs be it a pod or an orthopedist typically do when they see heel pain is say it is PF. How many people get misdiagnosed with PF? I don't know. I bet it is alot. The same holds true with TTS as well. I think that when a lot of people see someone come in with pain is that general region and is not responsive to the tried and true conservative modialities that work, they just tell the patients 'Ms. Jones....You got PF or TTS' and leave it at that. That's not being a diagnostician. That's just someone throwing their hands up in the air. I like to get it right. I don't every time. But I like to try. It's kind of a game. I would say and probably the other docs on here will tell you this as well that most patients can and will ultimately tell you what they have just through their clinical symptoms.

Re: Well, I may disagree on one thing

elliott on 7/31/02 at 10:43 (091139)

No matter; sticks and stones may break my bones...

:-)

Re: Well, I may disagree on one thing

Joe S on 7/31/02 at 12:51 (091148)

literally

Re: Joe S & Elliot

Pete R on 7/31/02 at 13:58 (091161)

Are you both pods / doctors etc ?

Re: Joe S & Elliot

elliott on 7/31/02 at 14:50 (091168)

He's a pod, I'm a nothing layman TTS/heelpain sufferer.

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