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PF Surgery vs. PF Rupture: Do they have the same outcomes?

Posted by Debra H. on 2/06/03 at 16:35 (108250)

There is an article posted on this website that indicates that in a study of 51 people with PF ruptures that 50% still had symptoms after 1 year. I've been told that one train of thought is that a PF rupture is a good thing because it does exactly what a PF surgical release would do. Does anyone know of a study of PF surgical relase outcomes? Do they have a better cure rate than only 50% at one year?

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

SteveG on 2/06/03 at 16:42 (108252)

Debra - This depends a lot on the study you look at. I have heard everything from 50% to 90%. I believe that Dr. Davis, one of the pods on this board, recently gave surgery about a 60-70% success rate.

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Debra H. on 2/06/03 at 16:46 (108253)

If this is true, then while 60-70% is still not that great, it would be better to have surgery than to wait for it to rupture. Or at least, PF rupture is NOT just like having the surgery done. Sure, it didn't cost me anything, but the outcomes are worse. Can anyone give me a reference to any of the studies on surgical outcomes of PF relase?

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

SteveG on 2/06/03 at 16:54 (108254)

Here is one, but as I say, you get a fair amount of variation depending on the study you look at -

http://www.curtin.edu.au/curtin/dept/physio/podiatry/encyclopedia/heelspursurgery/

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Debra H. on 2/06/03 at 17:32 (108260)

Does anyone know why a PF rupture has worse outcomes than a fasciotomy?

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Ed Davis, DPM on 2/06/03 at 18:30 (108270)

Debra:

The effect of a release is the same but surgery involves a 'clean' cut of the fascia while a rupture may involve a 'burst' with rough margins thus leading to more edema and scar tissue. Also, in surgery, we know how much of the fascia is being cut -- not the case in a tear.

The plantar fascia has a function to buttress the foot so sacrificing that structure via surgery is less than ideal. ESWT provides the hope of restoring the tissue quality of the fascia and preserving its function.
Ed

Re: A novel idea...?

Debra H. on 2/06/03 at 18:57 (108273)

Thankyou for your great responses! Here is a thought. Since it seems that either ESWT or even surgery are better than rupture, if someone goes to a podiatrist with a history of 8 years of PF despite great efforts at conservative management, why aren't they offered ESWT or fasciotomy sooner than the standard 6 months to one year? Why does a podiatrist start the clock the day they first see the patient rather than when conservative therapy began? (I'm not trying to pick on podiatrists, I think other medical professionals tend to do this as well.) It seems like everyone has 'their set of stretches' etc. that works better than anyone else's. It's kind of funny because when I first started going to physical therapy, for the first 3 visits I saw a different physical therapist because the main guy was on vacation. They each gave me a different set of stretches and said the other ones weren't sufficient. And, they all said the stretches given to me by my podiatrist were all wrong. It was quite confusing.

Re: A novel idea...?

Dr A. on 2/06/03 at 19:14 (108275)

If someone comes in with no treatment and 8 yrs. of pain, then traditional conservative treatment may cure them without the need for eswt. ESWT has its inherent risks and complications. The 6 months 'rule' is something that is imposed by insurance companies to limit over utilization (at least in my area). They don't want to pay for the treatment unless they really need to. If someone is self-pay and wants to have eswt, then the 6 month rule is thrown out the window and we don't have to play by the insurance company's rules.

Re: A novel idea...?

Dr. Z on 2/06/03 at 20:04 (108277)

I thought that the six month time frame was what has been used as an FDA guild that was transfer to some insurance companies. I have performed eSWT on patient at three months time period that have already exhausted every type of conservative treatment with the foot still in severe pain. They still did very well.

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Dr. Z on 2/06/03 at 20:09 (108278)

The surgical release also is a known amount of tear at a specific site. With a tear the cut could be in multiple sites with various amount of areas.
I agree with Dr. Ed Davis ESWT major advantage is that there is no sacrificing of the structure at all. This is what attracted Dr. Z to this procedure in the first place. There in no chance for a biomechanical destruction of this very important structure.
Until you have seen the permanent stuctural damage from a pf release you can't appreciate the benefits that ESWT provide. IF a patient only knew what they could be left with they would find the money no matter what to avoid this very serious complications that happen.

Re: A novel idea...?

Dr. Z on 2/06/03 at 20:19 (108282)

I would offer ESWT to someone that has had pf for eight years, with a few periods of relief and then recurrence. If their pain score is high this is an excellent candidate for ESWT

Re: How?

BrianG on 2/06/03 at 21:38 (108290)

Hi Deb,

Just wondering how you managed to rupture your PF? Was it easy, or did you have to really work at it, like competing in a triathalon, or something :*)

BrianG, not a doc

Re: Thank you for your responses, everyone!

Debra H. on 2/06/03 at 21:40 (108291)

This has been most informative, thank you.

Re: How?

Debra H. on 2/06/03 at 21:45 (108293)

It was really easy. I was trying to change directions and accelerate off that foot when I felt a big pop followed by intense pain. Keep in mind, I wasn't trying to do this. In fact, I didn't even know it was possible to rupture the PF. I'm in the medical field and have dissected out the PF of a cadaver. I remember it being a pretty tough piece of tissue.

Re: A novel idea...?

Julie on 2/07/03 at 04:03 (108301)

Debra, you've said you're in the medical field, so I guess you're well aware that amongst medical professionals views and opinions differ. I'm addressing the part of your post that points out the discrepancy between your physical therapists' views on stretching, and the fact that they all said the stretches your podiatrist gave you were wrong.

It seems that many if not most podiatrists still recommend the 'wall stretch' and even the 'hanging off the stair stretch' (were these the ones your podiatrist counselled?) Many people here have followed that advice, only to be made worse. These stretches, which may be fine for healthy feet and legs, are far too aggressive for injured tissues. Non-weight bearing exercise is preferable in almost all cases of PF.

If you see several professionals (i.e. PTs) and are offered different exercises by each, there is only one way to determine which are right and helpful for you. Try them cautiously, and observe their effects, and follow the bottom line rule: anything that causes pain is probably causing further injury, so - stop.

Re: A novel idea...?

nancy s. on 2/07/03 at 04:40 (108303)

debra, my first podiatrist offered no stretching guidelines at all. i wasn't aware that one should even be trying to stretch -- or trying to stay off the feet and give the injury time to heal.

by the time i had another doc and was sent to pt, a year later, i had found this website and knew a lot more about what i should try and what i should avoid.

my first pt was good in many ways, but within a month she was recommending the weight-bearing wall stretch to me, and i was still far from healed. i knew it would be wrong for me (in fact, i'd done it before and been made worse from it). got a new pt soon after, who was much more educated about how to treat pf. she had me doing only non-weight-bearing and very gradual stretching and strengthening for a long time.

i think the keys are (1) to listen to your own feet, as julie says, and (2) to self-educate as much as possible on this condition, because too many professionals sometimes don't seem aware of the most basic tenets of pf treatment. good doctors and good pt's will disagree at times, but in my mind some basic standards/do's&dont's for almost everyone with pf should apply. the kinds of stretching that should be done and those that should be avoided seem basic to me. but i wouldn't have known this -- and didn't know it -- until i educated myself, mostly on this site.

nancy
.

Re: A novel idea...?

Ed Davis, DPM on 2/07/03 at 20:04 (108405)

Dr. Z:

The 6 month figure can be arbitrary since a lot of the PF cases we see have had the problem for a long time. There are individuals making steady yet slow progress with conventional treatment 6 months out who appear to be heading toward resolution. Others may show no response whatsoever after 3 months of the same. I would rather use ESWT on the latter.
Ed

Re: surgery without anesthesia

Ed Davis, DPM on 2/07/03 at 20:06 (108407)

Debra:
I can really believe that the pain was 'intense'!
Ed

Re: surgery without anesthesia

BrianG on 2/07/03 at 20:35 (108413)

Oh god Dr Ed, just thinking about that pain is creeping me out.........

Re: A novel idea...?

Mar on 2/08/03 at 18:17 (108503)

Dr A -

What do you mean that ESWT has its inherent risks and complications? What might these be? When I had my ESWT done, I was told that there were NO risks. I'm just curious on the difference in 'opinion' here??? ... Mar

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

SteveG on 2/06/03 at 16:42 (108252)

Debra - This depends a lot on the study you look at. I have heard everything from 50% to 90%. I believe that Dr. Davis, one of the pods on this board, recently gave surgery about a 60-70% success rate.

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Debra H. on 2/06/03 at 16:46 (108253)

If this is true, then while 60-70% is still not that great, it would be better to have surgery than to wait for it to rupture. Or at least, PF rupture is NOT just like having the surgery done. Sure, it didn't cost me anything, but the outcomes are worse. Can anyone give me a reference to any of the studies on surgical outcomes of PF relase?

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

SteveG on 2/06/03 at 16:54 (108254)

Here is one, but as I say, you get a fair amount of variation depending on the study you look at -

http://www.curtin.edu.au/curtin/dept/physio/podiatry/encyclopedia/heelspursurgery/

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Debra H. on 2/06/03 at 17:32 (108260)

Does anyone know why a PF rupture has worse outcomes than a fasciotomy?

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Ed Davis, DPM on 2/06/03 at 18:30 (108270)

Debra:

The effect of a release is the same but surgery involves a 'clean' cut of the fascia while a rupture may involve a 'burst' with rough margins thus leading to more edema and scar tissue. Also, in surgery, we know how much of the fascia is being cut -- not the case in a tear.

The plantar fascia has a function to buttress the foot so sacrificing that structure via surgery is less than ideal. ESWT provides the hope of restoring the tissue quality of the fascia and preserving its function.
Ed

Re: A novel idea...?

Debra H. on 2/06/03 at 18:57 (108273)

Thankyou for your great responses! Here is a thought. Since it seems that either ESWT or even surgery are better than rupture, if someone goes to a podiatrist with a history of 8 years of PF despite great efforts at conservative management, why aren't they offered ESWT or fasciotomy sooner than the standard 6 months to one year? Why does a podiatrist start the clock the day they first see the patient rather than when conservative therapy began? (I'm not trying to pick on podiatrists, I think other medical professionals tend to do this as well.) It seems like everyone has 'their set of stretches' etc. that works better than anyone else's. It's kind of funny because when I first started going to physical therapy, for the first 3 visits I saw a different physical therapist because the main guy was on vacation. They each gave me a different set of stretches and said the other ones weren't sufficient. And, they all said the stretches given to me by my podiatrist were all wrong. It was quite confusing.

Re: A novel idea...?

Dr A. on 2/06/03 at 19:14 (108275)

If someone comes in with no treatment and 8 yrs. of pain, then traditional conservative treatment may cure them without the need for eswt. ESWT has its inherent risks and complications. The 6 months 'rule' is something that is imposed by insurance companies to limit over utilization (at least in my area). They don't want to pay for the treatment unless they really need to. If someone is self-pay and wants to have eswt, then the 6 month rule is thrown out the window and we don't have to play by the insurance company's rules.

Re: A novel idea...?

Dr. Z on 2/06/03 at 20:04 (108277)

I thought that the six month time frame was what has been used as an FDA guild that was transfer to some insurance companies. I have performed eSWT on patient at three months time period that have already exhausted every type of conservative treatment with the foot still in severe pain. They still did very well.

Re: PF Surgery vs. PF Rupture: Do they have the same outcomes?

Dr. Z on 2/06/03 at 20:09 (108278)

The surgical release also is a known amount of tear at a specific site. With a tear the cut could be in multiple sites with various amount of areas.
I agree with Dr. Ed Davis ESWT major advantage is that there is no sacrificing of the structure at all. This is what attracted Dr. Z to this procedure in the first place. There in no chance for a biomechanical destruction of this very important structure.
Until you have seen the permanent stuctural damage from a pf release you can't appreciate the benefits that ESWT provide. IF a patient only knew what they could be left with they would find the money no matter what to avoid this very serious complications that happen.

Re: A novel idea...?

Dr. Z on 2/06/03 at 20:19 (108282)

I would offer ESWT to someone that has had pf for eight years, with a few periods of relief and then recurrence. If their pain score is high this is an excellent candidate for ESWT

Re: How?

BrianG on 2/06/03 at 21:38 (108290)

Hi Deb,

Just wondering how you managed to rupture your PF? Was it easy, or did you have to really work at it, like competing in a triathalon, or something :*)

BrianG, not a doc

Re: Thank you for your responses, everyone!

Debra H. on 2/06/03 at 21:40 (108291)

This has been most informative, thank you.

Re: How?

Debra H. on 2/06/03 at 21:45 (108293)

It was really easy. I was trying to change directions and accelerate off that foot when I felt a big pop followed by intense pain. Keep in mind, I wasn't trying to do this. In fact, I didn't even know it was possible to rupture the PF. I'm in the medical field and have dissected out the PF of a cadaver. I remember it being a pretty tough piece of tissue.

Re: A novel idea...?

Julie on 2/07/03 at 04:03 (108301)

Debra, you've said you're in the medical field, so I guess you're well aware that amongst medical professionals views and opinions differ. I'm addressing the part of your post that points out the discrepancy between your physical therapists' views on stretching, and the fact that they all said the stretches your podiatrist gave you were wrong.

It seems that many if not most podiatrists still recommend the 'wall stretch' and even the 'hanging off the stair stretch' (were these the ones your podiatrist counselled?) Many people here have followed that advice, only to be made worse. These stretches, which may be fine for healthy feet and legs, are far too aggressive for injured tissues. Non-weight bearing exercise is preferable in almost all cases of PF.

If you see several professionals (i.e. PTs) and are offered different exercises by each, there is only one way to determine which are right and helpful for you. Try them cautiously, and observe their effects, and follow the bottom line rule: anything that causes pain is probably causing further injury, so - stop.

Re: A novel idea...?

nancy s. on 2/07/03 at 04:40 (108303)

debra, my first podiatrist offered no stretching guidelines at all. i wasn't aware that one should even be trying to stretch -- or trying to stay off the feet and give the injury time to heal.

by the time i had another doc and was sent to pt, a year later, i had found this website and knew a lot more about what i should try and what i should avoid.

my first pt was good in many ways, but within a month she was recommending the weight-bearing wall stretch to me, and i was still far from healed. i knew it would be wrong for me (in fact, i'd done it before and been made worse from it). got a new pt soon after, who was much more educated about how to treat pf. she had me doing only non-weight-bearing and very gradual stretching and strengthening for a long time.

i think the keys are (1) to listen to your own feet, as julie says, and (2) to self-educate as much as possible on this condition, because too many professionals sometimes don't seem aware of the most basic tenets of pf treatment. good doctors and good pt's will disagree at times, but in my mind some basic standards/do's&dont's for almost everyone with pf should apply. the kinds of stretching that should be done and those that should be avoided seem basic to me. but i wouldn't have known this -- and didn't know it -- until i educated myself, mostly on this site.

nancy
.

Re: A novel idea...?

Ed Davis, DPM on 2/07/03 at 20:04 (108405)

Dr. Z:

The 6 month figure can be arbitrary since a lot of the PF cases we see have had the problem for a long time. There are individuals making steady yet slow progress with conventional treatment 6 months out who appear to be heading toward resolution. Others may show no response whatsoever after 3 months of the same. I would rather use ESWT on the latter.
Ed

Re: surgery without anesthesia

Ed Davis, DPM on 2/07/03 at 20:06 (108407)

Debra:
I can really believe that the pain was 'intense'!
Ed

Re: surgery without anesthesia

BrianG on 2/07/03 at 20:35 (108413)

Oh god Dr Ed, just thinking about that pain is creeping me out.........

Re: A novel idea...?

Mar on 2/08/03 at 18:17 (108503)

Dr A -

What do you mean that ESWT has its inherent risks and complications? What might these be? When I had my ESWT done, I was told that there were NO risks. I'm just curious on the difference in 'opinion' here??? ... Mar