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Why the need for ESWT

Posted by Dr. Z on 9/18/02 at 20:23 (095659)

Failure to render adequate conservative treatment for plantar
fasciitis - Damage to plantar nerve - Loss of sensation to both feet

State: Pennsylvania

Facts: This medical malpractice action was brought by the male
plaintiff, who was approximately 34 years old at the time he was
treated by the defendant podiatrist for plantar fasciitis. The
plaintiff alleged that the defendant failed to attempt conservative
treatment prior to surgery, resulting in permanent damage to the
plantar nerve. The defendant maintained that conservative treatment
was attempted and failed necessitating the surgery.

The plaintiff presented to the defendant with plantar fasciitis, at
which time the defendant recommended surgery to both feet, according
to the plaintiff's claim. The plaintiff testified he was instructed
to return for surgery and he returned in February when the surgery
was performed. The plaintiff's expert podiatrist testified that
plantar nerve injury is a known risk of the surgery performed by the
defendant due to the fact that the nerve is not visible during the
procedure.

The plaintiff's plantar fasciitis should have been treated
conservatively using foot supports, arch supports, medication and
therapy for six months to a year, according to the plaintiff's
expert. This expert testified that such conservative treatment offers
a cure in more than 90% of all similar plantar fasciitis cases.
Evidence showed that during the surgery, the planter nerve in both of
the plaintiff's feet was damaged causing a loss of sensation to the
bottom of his right foot extending to his right toes and minor
sensation loss to his left foot.

The defendant argued that he attempted conservative treatment prior
to surgery. The defendant's expert podiatrist testified, based on his
review of the plaintiff's records, that the defendant prescribed foot
strapping on one occasion and medication on one occasion prior to
surgery. The period of conservative treatment failed and the surgery
was appropriate, according to the defendant's expert.

The jury found the defendant negligent and awarded the plaintiff $
75,000. An additional $ 24,000 in delay damages were added to the
award for a total recovery of $ 99,000 to the plaintiff.

Result: $ 75,000 verdict

Plaintiff expert: Jack Forman, DPM from Flemington, NJ

Defendant expert: Jack Gorman, DPM from Ben Salem, PA

Source: Medical Litigation Alert

Re: Why the need for ESWT

Pauline on 9/18/02 at 22:49 (095682)

Dr. Z,
I certainly agree with you on this.:*) In light of this article which certainly your colleague's must also read why are they still performing
P.F. release surgery?

If you can't convience them, how do you expect to convience their patient's who are at their mercy and believe them?

Re: Why the need for ESWT

Dr. Z on 9/19/02 at 08:30 (095700)

Rome was built in one day. There are many many patients that won't get a pf release end of story

Re: Why the need for ESWT

Pauline on 9/19/02 at 08:41 (095702)

Rome is still standing, many P.F. release patients are not.:*)

Re: Why the need for ESWT

Dr. Z on 9/19/02 at 08:44 (095703)

that was good one!!!! My first laugh for today

Re: Why the need for ESWT

Pauline on 9/19/02 at 08:52 (095705)

Always here to help you live your day to it's fullest:*) Have a good one.

Re: no, this is why the need for conservative treatments before surgery

elliott on 9/19/02 at 09:16 (095710)

Or maybe why Drs. hate lawyers. Or maybe why we all hate lawyers. Or maybe that there's too many shady unsavory incompetent DPMs out there. Or maybe that patients sue every time things don't go well. The list goes on. I wouldn't necessarily reject ESWT either if it turns out one case goes awry because of it.

Dr. Z, every long-term PF sufferer hopes that something like ESWT will come to the rescue. The main Dornier Epos study, a quality study, seems a great start (although I wouldn't completely discount what Pauline, negative as she might sometimes sound, is saying about Dr. Zingas either--do you think she is outright lying?). But, if no one else will say this (I'll bet many have wanted to), I wish you wouldn't automatically and unequivocally jump to accept every shred of evidence supporting the efficacy of ESWT and jump to shred every shred of evidence counter to ESWT, especially in light of your potential financial gain. You'd have more credibility in my eyes if you didn't. The quality of medical studies varies tremendously, retractions or less glowing revisions are de rigueur, and sometimes followup studies with stricter and saner criteria show that the glowing results of even some of the better studies can't be reproduced. I'll chime in that if it really is true that 80% or whatever of people get better in less than a year, then at least given the current cost of ESWT and the lack of evidence that waiting a year diminishes the chances of ESWT success, that maybe another study setting a MINIMUM of one or two years with PF might be illuminating, which way I'm not sure.

------

Re: no, this is why the need for conservative treatments before surgery

Dr. Z on 9/19/02 at 09:25 (095712)

Did you know that everyone in the Dornier FDA study had pain for TWO years

From my own personal experience in seeing ESWT for the past three years is that is works without the complications of foot surgery. Yes studies are always needed and will be done. But to use the AMA study as a comparison to the FDA dornier study is outrageous. That is my point and my own point at this time

Re: just to clarify

elliott on 9/19/02 at 15:08 (095738)

You're saying EVERYONE in the Dornier Epos FDA study had pain for two years (MINIMUM), and not just that the AVERAGE pain duration before ESWT treatment was two years. Is that correct?

[[[[[

Re: Why the need for ESWT

Ed Davis, DPM on 9/19/02 at 18:10 (095763)

That doctor violated the standard of care which involves a reasonable effort to resolve PF via conservative means before opting for surgery.
The majority of practitioners do follow the standard of care. There is still a role for PF release surgery and the need for it and surgeons who perform it will continue to exist. The advent of ESWT provides a major advance in the armementarium of conservative treatment so the number of PF release surgeries should continue to decrease.
Ed

Re: A few things to ponder

Ed Davis, DPM on 9/19/02 at 18:14 (095764)

It is important that doctors determine the standard of care, not trial lawyers nor insurance companies. What happens when an insurer denies ESWT and the patient then goes on to surgery which does not work? Why is the insurer not liable for standing at odds with the standard of care?
Ed

Re: just to clarify

Joe S on 9/19/02 at 19:27 (095773)

In clinical studies there are criteria that must be met. For instance you would be excluded if you had PF for less than two years. The only problem is that how do you prove it? There could be a ton of patients lie about the duration. Is the criteria based on the initial presentation for the complaint? I don't know.

Re: just to clarify

Pauline on 9/19/02 at 19:42 (095775)

Dr. Joe,
Couldn't you set the date based on the first visit to the doctors office where the patient got the diagnosis of P.F. A doctors records would have to be used to prove the date the patient entered his office. This could be matched with insurance billing if necessary for back up.

Certainly lots of work, but if you want pure you've got to filter the muddy water I guess.

Re: just to clarify

Dr. Z on 9/19/02 at 21:12 (095783)

That is what I was told. Even if the average was two years that is so different then the AMA study of at least six weeks. Two different studies

Re: A few things to ponder

BGCPed on 9/19/02 at 22:03 (095785)

BECAUSE OF TOO MANY LAWYERS THAT ARE ON A LEASH THAT IS TOO LONG.

Re: just to clarify

Joe S on 9/20/02 at 20:02 (095873)

You could but I would think it would be pretty hard to enroll alot of people into the study who just walked into your office with heel pain. My wife works in clinical research for an allergy medication. The protocols for conducting a multicenter clinical trial are very stringent. To study drugs like claritin versus allegra every the inclusion / exclusion protocols filled up a 1' binder. I would think for this type of study, some proof would have to be given that the test subject has suffered with PF for two years and has been treated for it over a two year period. You could find the initial treating physician and have the patient bring a copy of the medical records and so forth.

Re: Why the need for ESWT

Pauline on 9/18/02 at 22:49 (095682)

Dr. Z,
I certainly agree with you on this.:*) In light of this article which certainly your colleague's must also read why are they still performing
P.F. release surgery?

If you can't convience them, how do you expect to convience their patient's who are at their mercy and believe them?

Re: Why the need for ESWT

Dr. Z on 9/19/02 at 08:30 (095700)

Rome was built in one day. There are many many patients that won't get a pf release end of story

Re: Why the need for ESWT

Pauline on 9/19/02 at 08:41 (095702)

Rome is still standing, many P.F. release patients are not.:*)

Re: Why the need for ESWT

Dr. Z on 9/19/02 at 08:44 (095703)

that was good one!!!! My first laugh for today

Re: Why the need for ESWT

Pauline on 9/19/02 at 08:52 (095705)

Always here to help you live your day to it's fullest:*) Have a good one.

Re: no, this is why the need for conservative treatments before surgery

elliott on 9/19/02 at 09:16 (095710)

Or maybe why Drs. hate lawyers. Or maybe why we all hate lawyers. Or maybe that there's too many shady unsavory incompetent DPMs out there. Or maybe that patients sue every time things don't go well. The list goes on. I wouldn't necessarily reject ESWT either if it turns out one case goes awry because of it.

Dr. Z, every long-term PF sufferer hopes that something like ESWT will come to the rescue. The main Dornier Epos study, a quality study, seems a great start (although I wouldn't completely discount what Pauline, negative as she might sometimes sound, is saying about Dr. Zingas either--do you think she is outright lying?). But, if no one else will say this (I'll bet many have wanted to), I wish you wouldn't automatically and unequivocally jump to accept every shred of evidence supporting the efficacy of ESWT and jump to shred every shred of evidence counter to ESWT, especially in light of your potential financial gain. You'd have more credibility in my eyes if you didn't. The quality of medical studies varies tremendously, retractions or less glowing revisions are de rigueur, and sometimes followup studies with stricter and saner criteria show that the glowing results of even some of the better studies can't be reproduced. I'll chime in that if it really is true that 80% or whatever of people get better in less than a year, then at least given the current cost of ESWT and the lack of evidence that waiting a year diminishes the chances of ESWT success, that maybe another study setting a MINIMUM of one or two years with PF might be illuminating, which way I'm not sure.

------

Re: no, this is why the need for conservative treatments before surgery

Dr. Z on 9/19/02 at 09:25 (095712)

Did you know that everyone in the Dornier FDA study had pain for TWO years

From my own personal experience in seeing ESWT for the past three years is that is works without the complications of foot surgery. Yes studies are always needed and will be done. But to use the AMA study as a comparison to the FDA dornier study is outrageous. That is my point and my own point at this time

Re: just to clarify

elliott on 9/19/02 at 15:08 (095738)

You're saying EVERYONE in the Dornier Epos FDA study had pain for two years (MINIMUM), and not just that the AVERAGE pain duration before ESWT treatment was two years. Is that correct?

[[[[[

Re: Why the need for ESWT

Ed Davis, DPM on 9/19/02 at 18:10 (095763)

That doctor violated the standard of care which involves a reasonable effort to resolve PF via conservative means before opting for surgery.
The majority of practitioners do follow the standard of care. There is still a role for PF release surgery and the need for it and surgeons who perform it will continue to exist. The advent of ESWT provides a major advance in the armementarium of conservative treatment so the number of PF release surgeries should continue to decrease.
Ed

Re: A few things to ponder

Ed Davis, DPM on 9/19/02 at 18:14 (095764)

It is important that doctors determine the standard of care, not trial lawyers nor insurance companies. What happens when an insurer denies ESWT and the patient then goes on to surgery which does not work? Why is the insurer not liable for standing at odds with the standard of care?
Ed

Re: just to clarify

Joe S on 9/19/02 at 19:27 (095773)

In clinical studies there are criteria that must be met. For instance you would be excluded if you had PF for less than two years. The only problem is that how do you prove it? There could be a ton of patients lie about the duration. Is the criteria based on the initial presentation for the complaint? I don't know.

Re: just to clarify

Pauline on 9/19/02 at 19:42 (095775)

Dr. Joe,
Couldn't you set the date based on the first visit to the doctors office where the patient got the diagnosis of P.F. A doctors records would have to be used to prove the date the patient entered his office. This could be matched with insurance billing if necessary for back up.

Certainly lots of work, but if you want pure you've got to filter the muddy water I guess.

Re: just to clarify

Dr. Z on 9/19/02 at 21:12 (095783)

That is what I was told. Even if the average was two years that is so different then the AMA study of at least six weeks. Two different studies

Re: A few things to ponder

BGCPed on 9/19/02 at 22:03 (095785)

BECAUSE OF TOO MANY LAWYERS THAT ARE ON A LEASH THAT IS TOO LONG.

Re: just to clarify

Joe S on 9/20/02 at 20:02 (095873)

You could but I would think it would be pretty hard to enroll alot of people into the study who just walked into your office with heel pain. My wife works in clinical research for an allergy medication. The protocols for conducting a multicenter clinical trial are very stringent. To study drugs like claritin versus allegra every the inclusion / exclusion protocols filled up a 1' binder. I would think for this type of study, some proof would have to be given that the test subject has suffered with PF for two years and has been treated for it over a two year period. You could find the initial treating physician and have the patient bring a copy of the medical records and so forth.