Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

Stress Fracture after surgery???

Posted by Amy M. on 2/21/04 at 13:40 (144931)

I'm just checking to see if anyone has experienced a stress fracture after surgery for PF? (EPF)

The doctor thinks I have a stress fracture now after having EPF a few weeks ago.....(He never said it was related, but I was wondering if it could be since I don't remember doing anything to my foot that would harm it.)

Any advice would be helpful...

Amy M. in Minnesota

Re: Stress Fracture after surgery???

Ed Davis, DPM on 2/21/04 at 14:00 (144932)

This tends to be a fairly common complication that is usually avoided by placement of casts after surgery.
Ed Davis, DPM

Re: Stress Fracture after surgery???

Pauline on 2/21/04 at 14:15 (144936)

One wouldn't think a strss fracture would be a common complication following P.F. surgery. Most of our posters have not told us they were placed in any type of cast as all. In fact, many have been told to 'push' it and go back to work almost immediately.

When you say it's a fairly common complication, how common, and why do you think we haven't seen posters tell us their doctors told them this prior to release surgery?

Re: Stress Fracture after surgery???

Dorothy on 2/21/04 at 14:41 (144941)

Pauline ~ I do appreciate your healthy skepticism here very much. I think it keeps everyone on their toes (so to speak :-) ) and is a valuable 'service'. It's helpful that posters like you and elliott, for example, question and probe and seek solid information.

Re: Stress Fracture after surgery???

Pauline on 2/21/04 at 15:13 (144942)

Dorothy,
If we are to learn shouldn't we all be all be seeking and probing? Were you a bit surprised by the statement that stress fractures are rather common place for what is portrayed as a simple surgical procedure. I am.

Re: Stress Fracture after surgery???

Dorothy on 2/21/04 at 15:22 (144943)

Yes, I was - but I don't think I would have realized that it was a surprising statement had you not drawn attention to it - and that is why I thanked you, among other reasons from previous posts.

Re: Stress Fracture after surgery???

Ed Davis, DPM on 2/21/04 at 15:50 (144945)

Pauline:
If you look at a lot of the marketing of EPF that got so many upset a few years ago, some practitioners were running ads stating that one would be back in regular shoes within a few days. I am hoping that such marketing and practices has ceased.

I am not aware of specific statistics on this as our 'threshold' to accept surgery( in terms of general acceptance in the medical community and by third parties) has been much lower than that for medical devices such as ESWT. Additionally, I and colleagues I work with see very few stress fractures since we would regularly cast patients after such surgeries

Also, keep in mind that a percentage of stress fractures go undiagnosed. A significant percetnage of patients have long bouts of pain after such surgeries while others do fairly well. How often are bone scans being done on those individuals in persistent pain after surgery?

The plantar fascia has a significant physiologic/biomechanical function which is lost after surgery so it takes the body a while to adjust to the changes that have been effected. A major 'strut' supporting the heel bone and midtarsal joint has been sacrificed when plantar fascial release surgery is performed.
Ed

Re: addendum

Ed Davis, DPM on 2/21/04 at 15:56 (144946)

Wish there were more 'statistics' out there BUT, again, the burden of proof needed to take someone to surgery and the burden of data production needed to prove surgical efficacy is just so much less than that needed to approve a drug or medical device that not a lot has been written onthis psecific area. My perspective is from the collective experience of myself and colleagues.
Ed

Re: Stress Fracture after surgery???

Pauline on 2/21/04 at 15:57 (144947)

I think the people that have been around a while are pretty preceptive. We can't be the only ones surprised by this statement.

Re: addendum

Pauline on 2/21/04 at 16:26 (144954)

Dr. Ed,
Your saying docs are cutting the pilings knowing the pier won't stay up allowing a ship to run into the seawall and crack.

I don't think a drunken sailor would do this much damage:*

Re: addendum

Ed Davis, DPM on 2/21/04 at 17:25 (144962)

Sort of. When you don't know what else to do -- 'cut and burn.' It has always been the path of least resistance in American medicine -- our system seems to revolve around it. Virtually no one has ever been harmed by ESWT but we are in the midst of a knock down drag out battle to get it accepted here while the European and Australian docs look on in utter disbelief (I have developed wuite a few foreign pen pals who have a hard time understanding our way of doing things). I will be spending most of Tues. Feb 24 at a hearing at my State's attorney generals office helping to defend, without pay, a worker's compensation patient who opted for ESWT instead of surgery.

Ethical docs embraced ESWT with open arms because they realized the drawbacks to cutting the plantar fascia. It really does not matter which technique one uses to cut the plantar fascia as the effect of losing the 'strut' that was placed there at birth has never been desirable. When a structure is lost, it takes the body time to find a means to adapt to get along without it. That is why casting, physical therapy and time is needed for recovery -- something that has always been stressed to patients opting for that procedure. When EPF became 'popular' it was being 'sold' a high tech procedure to cure people faster. It did not do so and never will. Many advertised the procedure as a means to get back to activities quickly ad back to regular shoes in 'days,' all serious exaggerations but the FDA only looks at 'devices' and 'drugs,' not surgery.

Ed

Re: Stress Fracture after surgery???

Ed Davis, DPM on 2/21/04 at 17:40 (144964)

Pauline:
If you have two pieces of wood held together by 4 nails and I pull out two of the nails, do you think I have increased the chances that the two pieces of wood will separate? We don't need a double blind multicenter study to see what is going to happen but need to understand the function of what those nails are doing. By the same reasoning, it is not simply a matter of 'perception' but it takes an understanding of exactly what the plantar fascia does to understand the effects of cutting it. ScottR is an engineer so his explainations of the function of the fascia in his 'Heel Pain Book' are a good place to start. Then, take some time going back through the history of this site --- it is a site I still send patients to who are convinced that surgery is the way to go-- they almost all come back with a very different opinion about the role of surgery and what to expect from it.
Ed

Re: PS If BrianG, Dr. Z and ScottR are reading this response, I invite their input...

Ed Davis, DPM on 2/21/04 at 17:43 (144965)

ibid.
Ed

Re: Stress Fracture after surgery???

Pauline on 2/21/04 at 19:13 (144974)

I would hope so. I know Pete posted he's considering surgery as his final alternative. What will be his chance for a more positive outcome if he chooses the slide technique in the calf over EPF or open PF surgery?

Re: Stress Fracture after surgery???

Ed Davis, DPM on 2/21/04 at 19:42 (144979)

Pauline:
The concept behind the gastroc. slide is that an overly tight achilles (gastrosoleus-achilles complex) is part of the culprit in PF. If it is tight, then there is benefit to be obtained from the slide: if not tight, then no benefit. If the tightness is only modest, a combination of a night splint, good physical therapist with a focus on manual therapy and yoga can certainly work together to overcome that portion of the problem.

We consider 15 degrees of dorsiflexion (bending the foot back on the leg) to be optimal. If someone has about 5 degrees already available, it would not be too hard to obtain the additional 10 degrees with the aforementioned techniques. I actaully has two patients that I did slides on last week -- they had a negative 5 degrees, that is, would have required 20 degrees of improvement and decided that that was too far to go conservatively.
Ed

Re: My EPF results

BrianG on 2/21/04 at 20:41 (144985)

I had an EPF surgery Sept, 1999. It was done by a young, cocky Pod, who was trained by his partner, who had been trained by Dr. Barrett. At no time was anything said about possible stress fractures. He did say I might have nerve pain on the side of my foot, which could easily be cured with cortisone shots. The release I signed from the anestheselogists was much more detailed.

I went home a couple hours after the surgery, with my foot wrapped, and a disposable surgical shoe that many people get. I was given a sheet of paper that was very aggressive in getting back to walking. He had me walking from the second day, so many minutes per HOUR. Every hour he wanted me up and walking, longer and longer!!! The pain was terrible for the first couple weeks, but I walked, just like he asked me to. After about a month, I could not keep up wth his schedule, which increased about twice a week. Where this Pod came up with this walking therapy, I have no idea. Also, he said I'd be back in my own sneakers after the first week, no way!!! I saw him after the first 10 days, when he removed the stitches. After that it was monthly, for 3 months. Never once did he suggest physical therapy. Apparently he thought that walking thru incredible pain was all I needed.

After 3 months, he finally released me, and I was no better than before the surgery. It took about another month before I was able to return to work ( Some sitting, standing, and walking). The first month or two back to work, I was still hurting more than before the surgery. So, in my case it took about 6 months for the surgical area to heal, but at no time was it ever better than before the surgery. What gets me is that all the EPF advertisng promised a much quicker return to work (than other typs) and with a better cure rate.

Sorry, you can't prove it by me. Maybe if I had been casted, the results would have been different. Unfortunaly this was all before I discovered Heelspurs.com. I thought I had done my homework, I was wrong!!

I know there have been some patients healed by EPF, but I doubt they had the same after care that I had.

Regards
BrianG

Re: My EPF results

Pauline on 2/21/04 at 21:41 (144990)

Brian,
I don't think I've seen your story before. What a horrible experience and now you still suffer.

I have to agree with you about the amount of advertised clip and go P.F. surgeries. You know we've seen our share of posters right here with the same expectations of being pain free, yet they never seem to materialize.
Instead many have turned into multiple snowballing surgeries leaving the patient worse than before the first surgery was ever done.

Personally I don't think people realize how many failed cases there are.
If only the victims could meet each other, they would have a lot to talk about.

Re: PS If BrianG, Dr. Z and ScottR are reading this response, I invite their input...

Dr. Z on 2/21/04 at 21:51 (144993)

Ed,

I really didn't see that many stress fractures post minimial incision pf release. There were many times I would order an mri post pf release if I felt the pain was out of portion to what I usually would expect. I rarely used a cast after MIS foot surgery. My experience with EPF is very limited. I just believe that you should place a sharp rod into to the foot blindly. This is just my opinion and I am not saying it can't be done

Re: My EPF results

Dorothy on 2/21/04 at 22:36 (144997)

Your story makes me wish that we could help you now as much as you have been helping people here for as long as I have been participating and probably longer. What you have gone through must have been such a profound disappointment. It makes the way that you help people here even more meaningful, because you have every reason to be angry and bitter - and maybe there is that, too; goodness knows, you'd be entitled - but what you show is interest and concern and shared information with others.
Best wishes, Brian G ~

Re: My EPF results

Ed Davis, DPM on 2/21/04 at 23:18 (144998)

Brian and Pauline:
I remember the time period well when EPF was being 'sold' as a new high tech, high cure procedure -- walk in and walk out cured. It was at its worse in the early 90's. Lowell Scott Weil Sr., DPM, podiatrist for the Chicago Bears and a nationally reknowned authority in my profession wrote an article about EPF entitled 'The Rape of the Plantar Fascia.' That article really put a damper on the trend in many areas. It never really became very popular in the Seattle area but there are areas of the south where individuals were literally being rounded up for the procedure. Some influential individuals who made a lot of money on the procedure came to power in the APMA and actually convinced the AMA to create a separate procedure code for EPF -- amazing when you consider that we still don't have a CPT (AMA recognized) procedure code for orthotics and are using a 'temporary' code for ESWT.
Ed

Re: PS If BrianG, Dr. Z and ScottR are reading this response, I invite their input...

Ed Davis, DPM on 2/21/04 at 23:22 (144999)

Dr. Z;
I think it depends on a number of factors -- patient weight, occupation, avocation and biomechanics. I have a number of individuals who are factory workers (Boeing) stnding on concrete for long hours. It also depends on how compliant the patient is and how much they slowed down after the procedure.
Ed

Re: My EPF results

Ed Davis, DPM on 2/21/04 at 23:28 (145000)

Brian:
There have been studies comparing EPF to MIS to open. Initially MIS seems to have the least discomfort but long term results are fairly similar for all three. I feel that there is less opportunity for scar tissue to form with MIS as it is the least traumatic of the three. Of course, the best option is to avoid the surgery if possible, saving it as a last resort only. ESWT would have been available only in Canada and Europe in 1999, not the US. I am about 3 hours from Vancouver, BC so that would not stop me from having made such a referral although I have to admit that my knowledge of ESWT in 1999 was rudimentary.
Ed

Re: PS If BrianG, Dr. Z and ScottR are reading this response, I invite their input...

Dr. Z on 2/22/04 at 07:48 (145006)

That is very true. Factory works are out of work for at least 6-12 weeks. You can't send this type of worker back to the hard cement

Re: My EPF results

BrianG on 2/23/04 at 14:17 (145110)

Thanks Dorothy, I appreciate the kind words. I have my share of bad days, but thanks to my doc and pain meds, I continue to have hope! ...............BrianG

Re: My EPF results

Dorothy on 2/23/04 at 15:59 (145113)

Keep on hoping and trying and exploring. Good wishes ~

Re: My EPF results

Shaula H on 4/06/04 at 01:48 (148461)

Dr. Davis,
I had EPF eight months ago. The podiatrist said that I shouldn't bother with conventional treatment like shots and orthotics. He said conventional treatment usually didn't work and that most people had to have the surgery anyway after going through all that. I didn't know any better so I believed him. He did the EPF surgery on both my feet one week after I first saw him for PF. My feet never got better, they are worse now and hurt terribly, all the time, in places they never hurt before. Now I can't walk very well or stand very long. I am afraid that I will never be able to walk well again and I wonder if there is a doctor who can tell me what happened to my feet and knows how to fix them.